Healthcare Provider Details

I. General information

NPI: 1265700934
Provider Name (Legal Business Name): AMY DIANE LAGRANGE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 JEFFERSON ST NE SUITE 100
ALBUQUERQUE NM
87109-2136
US

IV. Provider business mailing address

933 BRADBURY SE SUITE 2222
ALBUQUERQUE NM
87106-4301
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-7464
  • Fax: 505-925-4539
Mailing address:
  • Phone: 505-272-2521
  • Fax: 505-272-3238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4833
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: