Provider Demographics
NPI:1194538074
Name:MILLER, AMANDA REA (RN, MSN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:REA
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN, MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 STONECREEK DR
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-1080
Mailing Address - Country:US
Mailing Address - Phone:618-779-6942
Mailing Address - Fax:
Practice Address - Street 1:12303 DEPAUL DR.
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-344-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021007992163WP0808X
MO2025002297363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health