Provider Demographics
NPI:1053013078
Name:CANCILLA, AMANDA BROOKE
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:BROOKE
Last Name:CANCILLA
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 1:9540 NORA LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1234
Mailing Address - Country:US
Mailing Address - Phone:317-679-4209
Mailing Address - Fax:
Practice Address - Street 1:13450 N MERIDIAN ST STE 145
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1484
Practice Address - Country:US
Practice Address - Phone:317-679-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other