Healthcare Provider Details

I. General information

NPI: 1326764580
Provider Name (Legal Business Name): AMANDA NICOLE CORDOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3836 LONESOME RIDGE CT NE # A
RIO RANCHO NM
87144-3725
US

IV. Provider business mailing address

3836 LONESOME RIDGE CT NE
RIO RANCHO NM
87144-3725
US

V. Phone/Fax

Practice location:
  • Phone: 714-661-7168
  • Fax:
Mailing address:
  • Phone: 714-661-7168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: