Basic Information
| Provider Information | |||||||||
| NPI: | 1972023810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KREIENKAMP | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | BROOKS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057537111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2017 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD2020-0740 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 2017020363 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.