1679138671 NPI number — PAMELA AMMONS NP-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679138671 NPI number — PAMELA AMMONS NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMMONS
Provider First Name:
PAMELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FITZGERALD
Provider Other First Name:
PAMELA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679138671
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 CAMINO DE VIDA SUITE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-472-4311
Provider Business Mailing Address Fax Number:
575-472-4313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RATON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87740-2002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-445-3626
Provider Business Practice Location Address Fax Number:
877-559-2708
Provider Enumeration Date:
05/06/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  CNP-55628 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 49574744 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 821448 . This is a "MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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