Basic Information
| Provider Information | |||||||||
| NPI: | 1710399654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIPPEN GODDARD | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | VIOLET | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 7001 SIGNAL AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871132453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058262735 | ||||||||
| FaxNumber: | 5058562749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | A233920 | NM | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 1D3719 | 01 | NM | MEDICARE PTAN | OTHER | 38337207 | 05 | NM | MEDICAID | 1D3721 | 01 | NM | MEDICARE PTAN | OTHER |