Healthcare Provider Details

I. General information

NPI: 1518207364
Provider Name (Legal Business Name): MANDI KAY SUSSEX-UPHOLD LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2013
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 21ST ST SE STE 4
RIO RANCHO NM
87124-4030
US

IV. Provider business mailing address

7009 CHRISTY AVE NE
ALBUQUERQUE NM
87109-3901
US

V. Phone/Fax

Practice location:
  • Phone: 505-402-3188
  • Fax:
Mailing address:
  • Phone: 505-402-3363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number7209
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: