Provider Demographics
NPI:1427816883
Name:MESA, AMY DANIELLE
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:DANIELLE
Last Name:MESA
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:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:TOME
Mailing Address - State:NM
Mailing Address - Zip Code:87060-0292
Mailing Address - Country:US
Mailing Address - Phone:505-312-0040
Mailing Address - Fax:505-213-0066
Practice Address - Street 1:400 GOLD AVE SW STE 301
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3283
Practice Address - Country:US
Practice Address - Phone:505-312-0040
Practice Address - Fax:505-213-0066
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator