Provider Demographics
NPI:1245424654
Name:LUNDSTROM, ALEISHA ANN
Entity Type:Individual
Prefix:
First Name:ALEISHA
Middle Name:ANN
Last Name:LUNDSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 ASH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-3001
Mailing Address - Country:US
Mailing Address - Phone:505-287-2190
Mailing Address - Fax:
Practice Address - Street 1:4216 BALLOON PARK RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5801
Practice Address - Country:US
Practice Address - Phone:505-344-5470
Practice Address - Fax:505-344-9343
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist