Provider Demographics
NPI:1952837825
Name:NASRALLAH, AMANDA S
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:NASRALLAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 GRANITE CIR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3304
Mailing Address - Country:US
Mailing Address - Phone:575-495-0542
Mailing Address - Fax:
Practice Address - Street 1:21 GRANITE CIR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3304
Practice Address - Country:US
Practice Address - Phone:575-495-0542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician