Provider Demographics
NPI:1104004514
Name:WRIGHT, DALISA J (CLMT)
Entity Type:Individual
Prefix:MS
First Name:DALISA
Middle Name:J
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:CLMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 N PRINCE ST
Mailing Address - Street 2:PMB 95
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4460
Mailing Address - Country:US
Mailing Address - Phone:505-763-5200
Mailing Address - Fax:
Practice Address - Street 1:116 PRAIRIEVIEW DR
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4234
Practice Address - Country:US
Practice Address - Phone:505-763-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM57752174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist