Provider Demographics
NPI:1740783067
Name:RUIZ, AMANDA ALIZABETH (LVN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ALIZABETH
Last Name:RUIZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10005 TEHAMA RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-7395
Mailing Address - Country:US
Mailing Address - Phone:361-396-2488
Mailing Address - Fax:
Practice Address - Street 1:10005 TEHAMA RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-7395
Practice Address - Country:US
Practice Address - Phone:361-396-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX330691164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse