1336332287 NPI number — MS. AMANDA D LUNDY RN SFA

Table of content: JEFFERY N MACDONALD MD (NPI 1669521563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336332287 NPI number — MS. AMANDA D LUNDY RN SFA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDY
Provider First Name:
AMANDA
Provider Middle Name:
D
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN SFA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336332287
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1390 E 20TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87401-9037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-599-8762
Provider Business Mailing Address Fax Number:
505-599-8796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1390 E 20TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401-9037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-599-8762
Provider Business Practice Location Address Fax Number:
505-599-8796
Provider Enumeration Date:
08/23/2007

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: 163WX0800X , with the licence number:  R52751 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WS0200X , with the licence number: R52751 , 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: 47522 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10035068 . This is a "LOVELACE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: R52751 . This is a "NEW MEXICO BOARD OF NURSI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 00NM006H20 . This is a "BCBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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