Provider Demographics
NPI:1003473679
Name:DEJESUS, AMY JOALYCE (RN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JOALYCE
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 HEART RD
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:AR
Mailing Address - Zip Code:72539-9504
Mailing Address - Country:US
Mailing Address - Phone:870-273-2595
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-2554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR90507163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency