Healthcare Provider Details

I. General information

NPI: 1285148072
Provider Name (Legal Business Name): TERESA PAEZ RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4705 MONTGOMERY BLVD NE STE 105
ALBUQUERQUE NM
87109-1246
US

IV. Provider business mailing address

4705 MONTGOMERY BLVD NE STE 105
ALBUQUERQUE NM
87109-1246
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-6797
  • Fax: 505-727-9979
Mailing address:
  • Phone: 505-727-6797
  • Fax: 505-727-9979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR26088
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL28802
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: