Basic Information
| Provider Information | |||||||||
| NPI: | 1760775639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALCH | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | BOUY | ||||||||
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| Credential: | WHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10170 SORRENTO VALLEY RD | ||||||||
| Address2: | MAIL DROP SV-5 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587845888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 951 MARINERS ISLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944041558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502856927 | ||||||||
| FaxNumber: | 8883527383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2011 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP20385 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.