MEDICARE: AMANDA HERRERA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	3205	NM

General Provider Information

NPI Number	:	1114055118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA HERRERA

Provider Business Mailing Address
First Line	:	PO BOX 253
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-0253
Country	:	US
Telephone Number	:	505-429-0296
Fax Number	:	505-454-9565

Provider Business Practice Location Address
First Line	:	220 PLAZA ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-3433
Country	:	US
Telephone Number	:	505-429-0296
Fax Number	:	505-454-9565

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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Directions to “ AMANDA HERRERA ” Practice Location

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