Healthcare Provider Details

I. General information

NPI: 1396852828
Provider Name (Legal Business Name): PAMELA ANN LIEURANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA ANN SHANKS RN

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

PO BOX 70552
ALBUQUERQUE NM
87197-0552
US

V. Phone/Fax

Practice location:
  • Phone: 150-599-1647
  • Fax: 150-525-6544
Mailing address:
  • Phone: 150-599-1619
  • Fax: 150-525-6544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0479953
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: