Healthcare Provider Details

I. General information

NPI: 1396480257
Provider Name (Legal Business Name): AMANDA MICHELLE BISCHOFF STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11335 SSG SIMS ST
FORT BLISS TX
79918-8033
US

IV. Provider business mailing address

11335 SSG SIMS ST
FORT BLISS TX
79918-8033
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-1107
  • Fax:
Mailing address:
  • Phone: 915-742-1107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number84325
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: