Provider Demographics
NPI:1952173791
Name:DECESARE, AMY (CCSS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DECESARE
Suffix:
Gender:F
Credentials:CCSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 MONTGOMERY BLVD NE STE V
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2470
Mailing Address - Country:US
Mailing Address - Phone:505-507-7984
Mailing Address - Fax:
Practice Address - Street 1:9201 MONTGOMERY BLVD NE STE V
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2470
Practice Address - Country:US
Practice Address - Phone:505-507-7984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-25
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCSS172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker