Provider Demographics
NPI:1407381056
Name:RODRIGUEZ, AMANDA ANN (AGACNP)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:ANN
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 TWIN DIAMOND RD.
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201
Mailing Address - Country:US
Mailing Address - Phone:605-484-1905
Mailing Address - Fax:
Practice Address - Street 1:1200 S. RICHARDSON
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203
Practice Address - Country:US
Practice Address - Phone:575-623-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM64625363LA2100X
TXAP132809363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care