Healthcare Provider Details

I. General information

NPI: 1962353607
Provider Name (Legal Business Name): AMANDA SABRIA NICKELBERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2026
Last Update Date: 02/09/2026
Certification Date: 02/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 GREENE ST NW STE 304
ALBUQUERQUE NM
87114-4284
US

IV. Provider business mailing address

2724 W DIVISION ST APT 3F
CHICAGO IL
60622-2825
US

V. Phone/Fax

Practice location:
  • Phone: 505-890-8678
  • Fax:
Mailing address:
  • Phone: 773-531-3285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-2026-0022
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: