Provider Demographics
NPI:1962919555
Name:WILBERG, AMIE CHRISTINE (RN)
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:CHRISTINE
Last Name:WILBERG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMIE
Other - Middle Name:CHRISTINE
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2609 N DAYTON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2305
Mailing Address - Country:US
Mailing Address - Phone:269-806-3625
Mailing Address - Fax:
Practice Address - Street 1:24 JOLIET ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1705
Practice Address - Country:US
Practice Address - Phone:219-865-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041410683163W00000X
IN28240509A163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse