Provider Demographics
NPI:1942522305
Name:MALDONADO, AMY JEANNIE (LMT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:JEANNIE
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:RUBY
Other - Last Name:MALDONADO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MMP
Mailing Address - Street 1:1330 BOSQUE FARMS BLVD
Mailing Address - Street 2:
Mailing Address - City:BOSQUE FARMS
Mailing Address - State:NM
Mailing Address - Zip Code:87068-9325
Mailing Address - Country:US
Mailing Address - Phone:505-916-0003
Mailing Address - Fax:
Practice Address - Street 1:1330 BOSQUE FARMS BLVD
Practice Address - Street 2:
Practice Address - City:BOSQUE FARMS
Practice Address - State:NM
Practice Address - Zip Code:87068-9325
Practice Address - Country:US
Practice Address - Phone:505-916-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2352225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist