Healthcare Provider Details

I. General information

NPI: 1295381069
Provider Name (Legal Business Name): AMANDA GAYLE DICKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 HILTON CORPORATE DRIVE
COLUMBUS OH
43232-4152
US

IV. Provider business mailing address

4715 HILTON CORPORATE DR
COLUMBUS OH
43232-4152
US

V. Phone/Fax

Practice location:
  • Phone: 614-647-2000
  • Fax: 828-287-4320
Mailing address:
  • Phone: 614-647-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.007537RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: