Provider Demographics
NPI:1043866940
Name:GILBREATH, AMY JOYCE (RN)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JOYCE
Last Name:GILBREATH
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:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:SAN JON
Mailing Address - State:NM
Mailing Address - Zip Code:88434-0005
Mailing Address - Country:US
Mailing Address - Phone:575-576-2466
Mailing Address - Fax:575-576-2772
Practice Address - Street 1:100 FRANKLIN ST.
Practice Address - Street 2:
Practice Address - City:GRADY
Practice Address - State:NM
Practice Address - Zip Code:88120
Practice Address - Country:US
Practice Address - Phone:575-576-2466
Practice Address - Fax:575-576-2772
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM57171163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty