Provider Demographics
NPI:1881866689
Name:MALLORY SPILLMAN, AMANDA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:MALLORY SPILLMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:
Practice Address - Street 1:10506 MONTGOMERY RD STE 209
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4400
Practice Address - Country:US
Practice Address - Phone:513-865-9040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002712RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant