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General NPI Number Information
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NPI Number | 1780473785
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Entity Type | Organization
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Legal Business Name | HEALTHY YOU PERSONALIZED PRIMARY CARE
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Dates
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Enumeration Date | 05/05/2025
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Last Update Date | 08/25/2025
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Provider Practice Location Address
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Address Line | 1240 S TELSHOR BLVD STE A
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City | LAS CRUCES
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State | NM
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Zip | 88011-4731
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Country | US
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Telephone | 575-915-8821
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Fax |
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Provider Business Mailing Address
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Address Line | 1240 S TELSHOR BLVD STE A
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City | LAS CRUCES
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State | NM
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Zip | 88011-4731
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Country | US
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Telephone | 575-259-3638
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Fax | 855-538-0781
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Authorized Official
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Title or Position | OWNER
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Name | AMANDA B. PROVENCIO
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Credential | MD
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Telephone | 575-259-3638
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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