Provider Demographics
NPI:1073118527
Name:REILLY, AMANDA NICHOLE (DC)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:NICHOLE
Last Name:REILLY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2636
Mailing Address - Country:US
Mailing Address - Phone:816-260-4315
Mailing Address - Fax:
Practice Address - Street 1:1010 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2636
Practice Address - Country:US
Practice Address - Phone:660-582-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020038723111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor