Healthcare Provider Details

I. General information

NPI: 1831529411
Provider Name (Legal Business Name): LORI A. WILLINGHURST, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 11/19/2013
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: 505-688-4598
  • Fax:
Mailing address:
  • Phone: 505-688-4598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number98199
License Number StateNM

VIII. Authorized Official

Name: DR. LORI WILLINGHURST
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 505-688-4598