Healthcare Provider Details

I. General information

NPI: 1235926916
Provider Name (Legal Business Name): AMANDA GALEN CROWLEY PA STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-7001
US

IV. Provider business mailing address

611 LONG OAK RD
MANTENO IL
60950-5034
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5000
  • Fax:
Mailing address:
  • Phone: 815-549-5445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: