Healthcare Provider Details

I. General information

NPI: 1750264354
Provider Name (Legal Business Name): AMANDA NICOLE KILGALLON PMHNP, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 NEW LONDON TPKE STE 1
NORWICH CT
06360-2645
US

IV. Provider business mailing address

108 NEW LONDON TPKE STE 1
NORWICH CT
06360-2645
US

V. Phone/Fax

Practice location:
  • Phone: 860-889-3052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number15148
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: