Healthcare Provider Details

I. General information

NPI: 1881947372
Provider Name (Legal Business Name): AMYLIA ASHLEY BLACK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2012
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST BLDG A
FARMINGTON NM
87401-8991
US

IV. Provider business mailing address

3208 N COCHITI AVE
FARMINGTON NM
87401-2052
US

V. Phone/Fax

Practice location:
  • Phone: 505-564-2300
  • Fax:
Mailing address:
  • Phone: 435-459-9881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number90687
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: