Provider Demographics
NPI:1477285567
Name:CROUCH, AMANDA RENEE (NPI)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:CROUCH
Suffix:
Gender:F
Credentials:NPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8416 HILTON AVE NE APT 9B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3134
Mailing Address - Country:US
Mailing Address - Phone:505-280-8063
Mailing Address - Fax:
Practice Address - Street 1:1400 BARBARA LOOP SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1088
Practice Address - Country:US
Practice Address - Phone:505-414-6449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM68222363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care