Provider Demographics
NPI:1023652633
Name:LONGFELLOW, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LONGFELLOW
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 1:1331 GUSDORF RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6282
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-747-7396
Practice Address - Street 1:2010 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3600
Practice Address - Country:US
Practice Address - Phone:505-753-7395
Practice Address - Fax:505-426-3492
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2019-0101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine