Provider Demographics
NPI:1316426588
Name:JIMENEZ, AMANDA INDALECIA (ACNP-AG)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:INDALECIA
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:ACNP-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-2525
Mailing Address - Country:US
Mailing Address - Phone:817-808-2700
Mailing Address - Fax:
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2363
Practice Address - Country:US
Practice Address - Phone:214-960-5681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138418363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care