Provider Demographics
NPI:1437882297
Name:FRAGOSO MONTANO, AMANDA DANIELLE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DANIELLE
Last Name:FRAGOSO MONTANO
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 1:339 NARA VISA CT NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6155
Mailing Address - Country:US
Mailing Address - Phone:150-555-4803
Mailing Address - Fax:
Practice Address - Street 1:339 NARA VISA CT NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6155
Practice Address - Country:US
Practice Address - Phone:505-554-8033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician