Healthcare Provider Details

I. General information

NPI: 1528604303
Provider Name (Legal Business Name): LISA SPERO CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 04/22/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PUEBLO VIEW
PENASCO NM
87553
US

IV. Provider business mailing address

PO BOX 755
ARROYO SECO NM
87514-0755
US

V. Phone/Fax

Practice location:
  • Phone: 575-251-8010
  • Fax: 833-438-5215
Mailing address:
  • Phone: 816-896-5472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number59011
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number59011
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: