Healthcare Provider Details

I. General information

NPI: 1770128753
Provider Name (Legal Business Name): AMANDA MACKILLOP NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54655 MAIN RD
SOUTHOLD NY
11971-4769
US

IV. Provider business mailing address

54655 MAIN RD
SOUTHOLD NY
11971-4769
US

V. Phone/Fax

Practice location:
  • Phone: 631-301-2271
  • Fax: 631-212-0482
Mailing address:
  • Phone: 631-301-2271
  • Fax: 631-212-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number403484
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number780342
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: