Provider Demographics
NPI:1144618752
Name:LOTT, MICHELLE ANN (DOM)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:LOTT
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 BUFFALO GRASS RD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3368
Mailing Address - Country:US
Mailing Address - Phone:503-740-5839
Mailing Address - Fax:
Practice Address - Street 1:3775 BUFFALO GRASS RD UNIT 3
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3368
Practice Address - Country:US
Practice Address - Phone:503-740-5839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist