Healthcare Provider Details

I. General information

NPI: 1275813560
Provider Name (Legal Business Name): AMANDA CUELLAR N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2061 ROSS AVENUE SUITE B
EL CENTRO CA
92243
US

IV. Provider business mailing address

516 WEST ATEN ROAD SUITE 2
IMPERIAL CA
92251
US

V. Phone/Fax

Practice location:
  • Phone: 760-352-5800
  • Fax: 760-352-0087
Mailing address:
  • Phone: 760-355-7730
  • Fax: 760-355-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN563858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: