MEDICARE: AMANDA MACKILLOP NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	403484	NY
2	163W00000X	Registered Nurse	780342	NY

General Provider Information

NPI Number	:	1770128753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MACKILLOP NP

Provider Business Mailing Address
First Line	:	54655 MAIN RD
Second Line	:
City	:	SOUTHOLD
State	:	NY
Zip	:	11971-4769
Country	:	US
Telephone Number	:	631-301-2271
Fax Number	:	631-212-0482

Provider Business Practice Location Address
First Line	:	54655 MAIN RD
Second Line	:
City	:	SOUTHOLD
State	:	NY
Zip	:	11971-4769
Country	:	US
Telephone Number	:	631-301-2271
Fax Number	:	631-212-0482

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2019
Last Update Date	:	12/17/2025

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