Provider Demographics
NPI:1215528187
Name:FARMER, AMANDA LEE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:FARMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:AIDONIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1222 JENNY DR APT G
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-9596
Mailing Address - Country:US
Mailing Address - Phone:630-317-4192
Mailing Address - Fax:
Practice Address - Street 1:1918 W FABYAN PKWY
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-1215
Practice Address - Country:US
Practice Address - Phone:630-482-2485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL10100711183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician