Healthcare Provider Details

I. General information

NPI: 1023652633
Provider Name (Legal Business Name): AMY LONGFELLOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 INDUSTRIAL PARK RD
ESPANOLA NM
87532-3600
US

IV. Provider business mailing address

1331 GUSDORF RD
TAOS NM
87571-6282
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-7395
  • Fax: 505-426-3492
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-747-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA2019-0101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: