Basic Information
| Provider Information | |||||||||
| NPI: | 1780326454 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASHAM | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JUNE | ||||||||
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| Credential: | FNP -BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3986 MARYVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620404191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187970618 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3986 MARYVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620404191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187970618 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2022 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209025025 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1811087604 | 01 | NPI | OTHER |