Healthcare Provider Details

I. General information

NPI: 1780524223
Provider Name (Legal Business Name): MAHOGANI LACY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CENTRAL AVE SW STE 1500E
ALBUQUERQUE NM
87102-3293
US

IV. Provider business mailing address

300 CENTRAL AVE SW STE 1500E
ALBUQUERQUE NM
87102-3293
US

V. Phone/Fax

Practice location:
  • Phone: 505-369-1731
  • Fax: 505-218-9307
Mailing address:
  • Phone: 505-369-1731
  • Fax: 505-218-9307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: