Healthcare Provider Details

I. General information

NPI: 1790894731
Provider Name (Legal Business Name): AMY BONNETT DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 JACKIE RD SE #102
RIO RANCHO NM
87124-1519
US

IV. Provider business mailing address

1350 JACKIE RD SE #102
RIO RANCHO NM
87124-1519
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-6965
  • Fax: 505-217-3791
Mailing address:
  • Phone: 505-896-6965
  • Fax: 505-217-3791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number906
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: