Provider Demographics
NPI:1700243524
Name:GILL, AMANDA J (HIS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:GILL
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15909 DUNKIRK ST NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5835
Mailing Address - Country:US
Mailing Address - Phone:763-232-0177
Mailing Address - Fax:
Practice Address - Street 1:13750 CROSSTOWN DR NW STE 107
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-5855
Practice Address - Country:US
Practice Address - Phone:612-255-1175
Practice Address - Fax:612-255-1176
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2774237700000X
FLAS 5066237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist