Healthcare Provider Details

I. General information

NPI: 1306504261
Provider Name (Legal Business Name): AMANDA M SKOTCHDOPOLE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 VENUS CT NE
ALBUQUERQUE NM
87112-3526
US

IV. Provider business mailing address

1921 VENUS CT NE
ALBUQUERQUE NM
87112-3526
US

V. Phone/Fax

Practice location:
  • Phone: 505-205-2755
  • Fax:
Mailing address:
  • Phone: 505-205-2755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-1159
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: