Provider Demographics
NPI:1710399654
Name:GRIPPEN GODDARD, AMANDA VIOLET (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:VIOLET
Last Name:GRIPPEN GODDARD
Suffix:
Gender:F
Credentials:DO
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 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:7001 SIGNAL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2453
Practice Address - Country:US
Practice Address - Phone:505-826-2735
Practice Address - Fax:505-856-2749
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA233920207K00000X
IADO-04892207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1D3719OtherMEDICARE PTAN
NM38337207Medicaid
NM1D3721OtherMEDICARE PTAN