Basic Information
| Provider Information | |||||||||
| NPI: | 1144822396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEAR | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACKENZIE | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13104 RADO DR N | ||||||||
| Address2: | |||||||||
| City: | HOMER GLEN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604918145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086000543 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4440 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086845187 | ||||||||
| FaxNumber: | 7085201875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2020 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LC0200X | 309016356 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine | 363LC0200X | 209021666 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
No ID Information.