Healthcare Provider Details

I. General information

NPI: 1538097795
Provider Name (Legal Business Name): AMANDA LYNN GREGORY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2026
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 HICKMAN RD
DES MOINES IA
50314-1597
US

IV. Provider business mailing address

727 NORELL AVE N
STILLWATER MN
55082-1947
US

V. Phone/Fax

Practice location:
  • Phone: 612-741-7981
  • Fax:
Mailing address:
  • Phone: 612-741-7981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: