Healthcare Provider Details

I. General information

NPI: 1932308855
Provider Name (Legal Business Name): AMANDA CALLOWAY PHILLIPS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NEIGHBORHOOD PL
FAIRDALE KY
40118-9697
US

IV. Provider business mailing address

PO BOX 950244
LOUISVILLE KY
40295-0244
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-2381
  • Fax: 502-363-1463
Mailing address:
  • Phone: 502-953-4700
  • Fax: 502-774-8631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28146751A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number71001599A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1093115
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: