Healthcare Provider Details

I. General information

NPI: 1548048010
Provider Name (Legal Business Name): AMY JO GOLLER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY JO IMBRIGIOTTA PMHNP-BC

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WALL ST
MANCHESTER NH
03101-1518
US

IV. Provider business mailing address

2 WALL ST STE 200
MANCHESTER NH
03101-1518
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-4111
  • Fax:
Mailing address:
  • Phone: 603-668-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number09305223
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11027279
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: