Provider Demographics
NPI:1114055118
Name:HERRERA, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HERRERA
Suffix:
Gender:F
Credentials:
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 253
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-0253
Mailing Address - Country:US
Mailing Address - Phone:505-429-0296
Mailing Address - Fax:505-454-9565
Practice Address - Street 1:220 PLAZA ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3433
Practice Address - Country:US
Practice Address - Phone:505-429-0296
Practice Address - Fax:505-454-9565
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist