Provider Demographics
NPI:1780473785
Name:HEALTHY YOU PERSONALIZED PRIMARY CARE
Entity type:Organization
Organization Name:HEALTHY YOU PERSONALIZED PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:PROVENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-915-8821
Mailing Address - Street 1:1240 S TELSHOR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4731
Mailing Address - Country:US
Mailing Address - Phone:575-915-8821
Mailing Address - Fax:
Practice Address - Street 1:1240 S TELSHOR BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4731
Practice Address - Country:US
Practice Address - Phone:575-915-8821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty