Healthcare Provider Details

I. General information

NPI: 1902551005
Provider Name (Legal Business Name): AMANDA DEATHERAGE APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W AVENUE I
LOVINGTON NM
88260-5002
US

IV. Provider business mailing address

901 W WILDY ST
ROSWELL NM
88203-3717
US

V. Phone/Fax

Practice location:
  • Phone: 806-928-9870
  • Fax: 806-243-6233
Mailing address:
  • Phone: 806-928-9870
  • Fax: 806-243-6233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1070110
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number67588
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: