Healthcare Provider Details

I. General information

NPI: 1962822601
Provider Name (Legal Business Name): AMANDA L GILLETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9680 TAMARACK RD STE 100
WOODBURY MN
55125-2617
US

IV. Provider business mailing address

9680 TAMARACK ROAD SUITE 100
WOODBURY MN
55125-2617
US

V. Phone/Fax

Practice location:
  • Phone: 651-738-0470
  • Fax: 651-738-8915
Mailing address:
  • Phone: 651-738-0470
  • Fax: 651-731-5031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61539
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: