Provider Demographics
NPI:1275098253
Name:GUEREQUE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GUEREQUE
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 1:4217 BIG SKY RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4845
Mailing Address - Country:US
Mailing Address - Phone:505-469-8887
Mailing Address - Fax:
Practice Address - Street 1:4217 BIG SKY RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4845
Practice Address - Country:US
Practice Address - Phone:505-469-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3618121567Medicaid