Provider Demographics
NPI:1063756492
Name:STAKER, AMY LYNN (APRN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:STAKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:100 GORE RD
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-9466
Practice Address - Country:US
Practice Address - Phone:815-364-8919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010035363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.010035OtherIL LICENSE
ILPENDINGMedicaid