Healthcare Provider Details

I. General information

NPI: 1659946093
Provider Name (Legal Business Name): AMANDA LEE GANNON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 10/14/2026
Certification Date: 10/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 SYLVAN ST
DANVERS MA
01923-3561
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 978-774-4500
  • Fax: 978-774-0974
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5477
License Number StateMA
# 2
Primary TaxonomyN
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: