Provider Demographics
NPI:1972023810
Name:KREIENKAMP, AMELIA BROOKS (MD)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:BROOKS
Last Name:KREIENKAMP
Suffix:
Gender:F
Credentials:MD
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 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:1010 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2724
Practice Address - Country:US
Practice Address - Phone:505-753-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-0740208000000X
MO2017020363208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics