Healthcare Provider Details

I. General information

NPI: 1477077782
Provider Name (Legal Business Name): LEA WILDFLOWER CMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RODEO RD RM 4
SANTA FE NM
87505-6378
US

IV. Provider business mailing address

941 CALLE MEJIA APT 511
SANTA FE NM
87501-1464
US

V. Phone/Fax

Practice location:
  • Phone: 415-320-3819
  • Fax:
Mailing address:
  • Phone: 415-320-3819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number22150
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2024-0172
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: