Provider Demographics
NPI:1962822601
Name:GILLETT, AMANDA L (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:GILLETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9680 TAMARACK ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2617
Mailing Address - Country:US
Mailing Address - Phone:651-738-0470
Mailing Address - Fax:651-731-5031
Practice Address - Street 1:9680 TAMARACK RD STE 100
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2617
Practice Address - Country:US
Practice Address - Phone:651-738-0470
Practice Address - Fax:651-738-8915
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN61539208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program