Basic Information
| Provider Information | |||||||||
| NPI: | 1710627534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUBBLEFIELD | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | RENEER | ||||||||
| NamePrefix: | |||||||||
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| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RENEER | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12377 MERIT DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752513126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729573000 | ||||||||
| FaxNumber: | 9729573005 | ||||||||
| Practice Location | |||||||||
| Address1: | 8535 BLANCO RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782163040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108800006 | ||||||||
| FaxNumber: | 2105791852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2022 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1089383 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.