Provider Demographics
NPI:1326473638
Name:MELENDEZ, LISA NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:MELENDEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 HAVASU FALLS ST NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144
Mailing Address - Country:US
Mailing Address - Phone:505-480-4518
Mailing Address - Fax:
Practice Address - Street 1:3610 HAVASU FALLS ST NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144
Practice Address - Country:US
Practice Address - Phone:505-480-4518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7571225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist