Healthcare Provider Details

I. General information

NPI: 1750577441
Provider Name (Legal Business Name): ANDREA SISNEROS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2007
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CARLISLE BLVD NE STE 21
ALBUQUERQUE NM
87110-1687
US

IV. Provider business mailing address

11713 MOCHO PL NE
ALBUQUERQUE NM
87123-1334
US

V. Phone/Fax

Practice location:
  • Phone: 505-710-5041
  • Fax:
Mailing address:
  • Phone: 505-710-5041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5068
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: