Provider Demographics
NPI:1376587022
Name:PAULL, AMANDA COLLEEN (OD MS)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:COLLEEN
Last Name:PAULL
Suffix:
Gender:F
Credentials:OD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4541 VILLAGE PARK DR E
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-2407
Mailing Address - Country:US
Mailing Address - Phone:804-263-7845
Mailing Address - Fax:804-335-1310
Practice Address - Street 1:9200 STONY POINT PKWY STE 195B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-1971
Practice Address - Country:US
Practice Address - Phone:804-272-0848
Practice Address - Fax:804-272-0849
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001501152W00000X, 152WC0802X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11558617OtherUNIVERSAL CREDENTIALING
VA0618001501OtherLICENSE
VAMP1549558OtherDEA LICENSE
VAV08938Medicare UPIN
VA0618001501OtherLICENSE