Healthcare Provider Details

I. General information

NPI: 1528603602
Provider Name (Legal Business Name): AMY LYNN WISHARD AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 N 13TH ST
ARTESIA NM
88210-1133
US

IV. Provider business mailing address

702 N 13TH ST
ARTESIA NM
88210-1199
US

V. Phone/Fax

Practice location:
  • Phone: 575-748-8301
  • Fax:
Mailing address:
  • Phone: 575-748-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number54477
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number54477
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: