Healthcare Provider Details

I. General information

NPI: 1003166984
Provider Name (Legal Business Name): AMANDA MONTELEONE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA PHOENIX P.A.

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 2015
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 2015
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-1700
  • Fax:
Mailing address:
  • Phone: 314-251-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004469
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2025008599
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: