Healthcare Provider Details

I. General information

NPI: 1396079208
Provider Name (Legal Business Name): AMANDA LYNN CARROLL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 10/11/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HIGHWAY 61 S. SUITE 340
FESTUS MO
63028
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 636-937-1545
  • Fax: 636-937-8995
Mailing address:
  • Phone: 314-364-7586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036134130
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2019010500
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: