Provider Demographics
NPI:1003166984
Name:MONTELEONE, AMANDA (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MONTELEONE
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:PHOENIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:621 S NEW BALLAS RD STE 2015
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-1700
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 2015
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004469363A00000X
MO2025008599363A00000X
IL085.004469207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01138784OtherRAILROAD
ILP01138784OtherRAILROAD
ILP01138784OtherRAILROAD