Healthcare Provider Details

I. General information

NPI: 1619864089
Provider Name (Legal Business Name): AMANDA RENEE PACHECO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 RIDGE RUNNER RD
LAS VEGAS NM
87701-4972
US

IV. Provider business mailing address

PO BOX 46
SERAFINA NM
87569-0046
US

V. Phone/Fax

Practice location:
  • Phone: 505-434-0119
  • Fax:
Mailing address:
  • Phone: 505-426-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number84599
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: