Healthcare Provider Details

I. General information

NPI: 1184933582
Provider Name (Legal Business Name): AMANDA KANWISCHER GUTIERREZ O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2010
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NEALY AVE
LANGLEY AFB VA
23665-2040
US

IV. Provider business mailing address

77 NEALY AVE
LANGLEY AFB VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-6973
  • Fax:
Mailing address:
  • Phone: 210-842-6957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8276
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: