Healthcare Provider Details

I. General information

NPI: 1801541040
Provider Name (Legal Business Name): AMANDA EWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

PO BOX 2666
ALBUQUERQUE NM
87125
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-5686
  • Fax: 505-559-6680
Mailing address:
  • Phone: 505-291-5686
  • Fax: 505-559-6680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number921
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: