Provider Demographics
NPI:1063401354
Name:HETTINGER, AMANDA BELLE (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:BELLE
Last Name:HETTINGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4123 DUTCHMANS LN
Practice Address - Street 2:SUITE 503
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4707
Practice Address - Country:US
Practice Address - Phone:502-409-5600
Practice Address - Fax:502-259-3078
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY426902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200528120Medicaid
OR272440Medicaid
KY64119936Medicaid
BM9242758OtherDEA
ORR137579Medicare PIN