Provider Demographics
NPI:1740424076
Name:MCCONNELL MACK, AMANDA NICHOLE (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICHOLE
Last Name:MCCONNELL MACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:NICHOLE
Other - Last Name:MCCONNELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5763
Mailing Address - Fax:740-446-5573
Practice Address - Street 1:90 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5763
Practice Address - Fax:740-446-5573
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0105752084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024041Medicaid
OH0069462Medicaid
WV3810024041Medicaid