Provider Demographics
NPI:1235471558
Name:VIGIL, AMBER N (LD)
Entity Type:Individual
Prefix:MISS
First Name:AMBER
Middle Name:N
Last Name:VIGIL
Suffix:
Gender:F
Credentials:LD
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 640
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-0640
Mailing Address - Country:US
Mailing Address - Phone:505-869-3200
Mailing Address - Fax:505-869-4881
Practice Address - Street 1:01 SAGEBRUSH RD.
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022
Practice Address - Country:US
Practice Address - Phone:505-869-3200
Practice Address - Fax:505-869-4881
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0884133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered