Provider Demographics
NPI:1043605447
Name:STOVALL, AMANDA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:STOVALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5208 N WEAVERRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-8984
Mailing Address - Country:US
Mailing Address - Phone:502-418-2991
Mailing Address - Fax:
Practice Address - Street 1:5208 N WEAVERRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-8984
Practice Address - Country:US
Practice Address - Phone:502-418-2991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INAPPLIED FOR390200000X
IL036.157682208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program