Healthcare Provider Details

I. General information

NPI: 1598320251
Provider Name (Legal Business Name): AMANDA CHRISTINE RENFRO AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 COMMONS AVE NE
ALBUQUERQUE NM
87109-5831
US

IV. Provider business mailing address

8524 W GAGE BLVD BLDG A1 BOX 319
KENNEWICK WA
99336-8241
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-7799
  • Fax:
Mailing address:
  • Phone: 509-591-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number56021
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number56021
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-56021
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: