Healthcare Provider Details

I. General information

NPI: 1013994961
Provider Name (Legal Business Name): LORI WILLINGHURST M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 HARDWARE DR NE SUITE 5
ALBUQUERQUE NM
87109-2013
US

IV. Provider business mailing address

4810 HARDWARE DR NE SUITE 5
ALBUQUERQUE NM
87109-2013
US

V. Phone/Fax

Practice location:
  • Phone: 505-401-2527
  • Fax: 505-255-4717
Mailing address:
  • Phone: 505-401-2527
  • Fax: 505-255-4717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number98199
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: