Provider Demographics
NPI:1396079208
Name:CARROLL, AMANDA LYNN (DO)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LYNN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:DO
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 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-364-7586
Mailing Address - Fax:
Practice Address - Street 1:1400 HIGHWAY 61 S.
Practice Address - Street 2:SUITE 340
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028
Practice Address - Country:US
Practice Address - Phone:636-937-1545
Practice Address - Fax:636-937-8995
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134130207V00000X
MO2019010500207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology