Healthcare Provider Details

I. General information

NPI: 1043885296
Provider Name (Legal Business Name): AMANDA GRACE VEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 COPPER LOOP
LAS CRUCES NM
88005-8139
US

IV. Provider business mailing address

2701 N 16TH ST STE 316
PHOENIX AZ
85006-1266
US

V. Phone/Fax

Practice location:
  • Phone: 575-449-8159
  • Fax:
Mailing address:
  • Phone: 602-650-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: