Healthcare Provider Details

I. General information

NPI: 1972926962
Provider Name (Legal Business Name): KIMBERLY RENEE LUSK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5011 APACHE HILLS DR
ROSWELL NM
88201-9484
US

IV. Provider business mailing address

300 N KENTUCKY AVE
ROSWELL NM
88201-4636
US

V. Phone/Fax

Practice location:
  • Phone: 575-317-3510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR54780
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: