Provider Demographics
NPI:1073792685
Name:WENGERD, LISA (LMT, CST)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WENGERD
Suffix:
Gender:F
Credentials:LMT, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 APPLEWOOD PARK DR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-7120
Mailing Address - Country:US
Mailing Address - Phone:505-264-8267
Mailing Address - Fax:
Practice Address - Street 1:624 APPLEWOOD PARK DR SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-7120
Practice Address - Country:US
Practice Address - Phone:505-264-8267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6662225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist