Healthcare Provider Details

I. General information

NPI: 1780473785
Provider Name (Legal Business Name): HEALTHY YOU PERSONALIZED PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 08/25/2025
Certification Date: 08/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 S TELSHOR BLVD STE A
LAS CRUCES NM
88011-4731
US

IV. Provider business mailing address

1240 S TELSHOR BLVD STE A
LAS CRUCES NM
88011-4731
US

V. Phone/Fax

Practice location:
  • Phone: 575-915-8821
  • Fax:
Mailing address:
  • Phone: 575-259-3638
  • Fax: 855-538-0781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AMANDA B. PROVENCIO
Title or Position: OWNER
Credential: MD
Phone: 575-259-3638