Healthcare Provider Details

I. General information

NPI: 1326720707
Provider Name (Legal Business Name): AMANDA R CANDELARIA MSN, APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 W DIDIER AVE
BELEN NM
87002-3160
US

IV. Provider business mailing address

838 W DIDIER AVE
BELEN NM
87002-3160
US

V. Phone/Fax

Practice location:
  • Phone: 505-525-5594
  • Fax:
Mailing address:
  • Phone: 505-525-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number56655
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: