Healthcare Provider Details

I. General information

NPI: 1548941842
Provider Name (Legal Business Name): AMANDA SICILIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 MATTOX DR
SULLIVAN MO
63080-2365
US

IV. Provider business mailing address

PO BOX 959318
SAINT LOUIS MO
63195-9318
US

V. Phone/Fax

Practice location:
  • Phone: 573-860-6000
  • Fax: 573-860-6016
Mailing address:
  • Phone: 573-860-6000
  • Fax: 573-860-6016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2026030843
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125082170
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: