Provider Demographics
NPI:1285969055
Name:BALLARD, AMANDA M (OD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:BALLARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:MATTINGLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:5855 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:502-955-2020
Mailing Address - Fax:502-736-4490
Practice Address - Street 1:325 W WALNUT ST
Practice Address - Street 2:STE400
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1377
Practice Address - Country:US
Practice Address - Phone:502-955-2020
Practice Address - Fax:502-736-4490
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1792DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100110940Medicaid
KY0959014Medicare PIN
KY5375220007Medicare NSC