Healthcare Provider Details

I. General information

NPI: 1477285567
Provider Name (Legal Business Name): AMANDA RENEE CROUCH NPI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BARBARA LOOP SE
RIO RANCHO NM
87124-1088
US

IV. Provider business mailing address

8416 HILTON AVE NE APT 9B
ALBUQUERQUE NM
87111-3134
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-6449
  • Fax:
Mailing address:
  • Phone: 505-280-8063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number68222
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: