Provider Demographics
NPI:1629776364
Name:MCQUILLEN, AMANDA KAY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:MCQUILLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8659 COLUMBUS PIKE
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-9699
Mailing Address - Country:US
Mailing Address - Phone:740-657-1301
Mailing Address - Fax:740-657-8442
Practice Address - Street 1:8659 COLUMBUS PIKE
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-9699
Practice Address - Country:US
Practice Address - Phone:740-657-1301
Practice Address - Fax:740-657-8442
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.015504-SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician