Provider Demographics
NPI:1679138671
Name:AMMONS, PAMELA (NP-C)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:AMMONS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:117 CAMINO DE VIDA SUITE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435
Mailing Address - Country:US
Mailing Address - Phone:575-472-4311
Mailing Address - Fax:575-472-4313
Practice Address - Street 1:166 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2002
Practice Address - Country:US
Practice Address - Phone:575-445-3626
Practice Address - Fax:877-559-2708
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-55628363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49574744Medicaid
NM821448OtherMEDICARE