Provider Demographics
NPI:1578517306
Name:KNICKERBOCKER, AMY JOANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:JOANNE
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:JOANNE
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 OAK RIDGE POND ROAD
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401
Mailing Address - Country:US
Mailing Address - Phone:573-406-5276
Mailing Address - Fax:573-406-1057
Practice Address - Street 1:3650 STARDUST DRIVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401
Practice Address - Country:US
Practice Address - Phone:573-406-1503
Practice Address - Fax:573-406-1057
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200143624152W00000X
IL046009247152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist