Healthcare Provider Details

I. General information

NPI: 1659842896
Provider Name (Legal Business Name): MRS. AMANDA M. PIERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 FIR LOOP
CEDAR CREST NM
87008-9468
US

IV. Provider business mailing address

10 FIR LOOP
CEDAR CREST NM
87008-9468
US

V. Phone/Fax

Practice location:
  • Phone: 505-353-2215
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: