Healthcare Provider Details

I. General information

NPI: 1285581207
Provider Name (Legal Business Name): LACIE D PEREGRINE-BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CARDENAS DR NE
ALBUQUERQUE NM
87108-1720
US

IV. Provider business mailing address

4724 GUADALUPE PEAK ST SW
LOS LUNAS NM
87031-9088
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-8168
  • Fax:
Mailing address:
  • Phone: 816-500-4814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: