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General NPI Number Information
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NPI Number | 1518207364
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Entity Type | Individual
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Provider Name | MANDI KAY SUSSEX-UPHOLD LMT
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Gender | Female
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Dates
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Enumeration Date | 02/14/2013
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Last Update Date | 02/14/2013
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Provider Practice Location Address
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Address Line | 1005 21ST ST SE STE 4
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City | RIO RANCHO
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State | NM
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Zip | 87124-4030
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Country | US
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Telephone | 505-402-3188
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Fax |
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Provider Business Mailing Address
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Address Line | 7009 CHRISTY AVE NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-3901
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Country | US
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Telephone | 505-402-3363
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 7209
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License Number State | NM
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