Provider Demographics
NPI:1194282061
Name:FITZGIBBON, AMY (NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FITZGIBBON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3801
Mailing Address - Country:US
Mailing Address - Phone:630-200-7096
Mailing Address - Fax:
Practice Address - Street 1:1620 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3801
Practice Address - Country:US
Practice Address - Phone:630-200-7096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011514363L00000X
MDR242201363L00000X
IL209026128363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner