Healthcare Provider Details

I. General information

NPI: 1477923274
Provider Name (Legal Business Name): CONSUELO MARIE GUAMBANA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 PACHECO ST STE 206
SANTA FE NM
87505-4222
US

IV. Provider business mailing address

2737 CALLE SERENA
SANTA FE NM
87505-5211
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-2449
  • Fax:
Mailing address:
  • Phone: 505-570-9383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4857
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: