Healthcare Provider Details

I. General information

NPI: 1568637965
Provider Name (Legal Business Name): AMANDA L CANNADY PT, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

IV. Provider business mailing address

7455 CARSON TRL NW
ALBUQUERQUE NM
87120-4525
US

V. Phone/Fax

Practice location:
  • Phone: 505-765-2370
  • Fax:
Mailing address:
  • Phone: 505-899-7653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number2469
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: