Provider Demographics
NPI:1891932414
Name:WHEAT, AMANDA (DOM)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WHEAT
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 77 BOX A11
Mailing Address - Street 2:
Mailing Address - City:OJO CALIENTE
Mailing Address - State:NM
Mailing Address - Zip Code:87549-9710
Mailing Address - Country:US
Mailing Address - Phone:505-927-5086
Mailing Address - Fax:
Practice Address - Street 1:239 PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-753-9296
Practice Address - Fax:505-747-7968
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist