Healthcare Provider Details

I. General information

NPI: 1053013078
Provider Name (Legal Business Name): MRS. AMANDA BROOKE CANCILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13450 N MERIDIAN ST STE 145
CARMEL IN
46032-1484
US

IV. Provider business mailing address

9540 NORA LN
INDIANAPOLIS IN
46240-1234
US

V. Phone/Fax

Practice location:
  • Phone: 317-679-4209
  • Fax:
Mailing address:
  • Phone: 317-679-4209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: