Basic Information
| Provider Information | |||||||||
| NPI: | 1578942686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEED | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24915 N COPPERAS CREEK RD | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615208644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092325183 | ||||||||
| FaxNumber: | 3096640969 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617014364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096623311 | ||||||||
| FaxNumber: | 3096640969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2200X | 209012318 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
No ID Information.