Provider Demographics
NPI:1477923274
Name:GUAMBANA, CONSUELO MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:CONSUELO
Middle Name:MARIE
Last Name:GUAMBANA
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 1:2737 CALLE SERENA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5211
Mailing Address - Country:US
Mailing Address - Phone:505-570-9383
Mailing Address - Fax:
Practice Address - Street 1:1348 PACHECO ST STE 206
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4222
Practice Address - Country:US
Practice Address - Phone:505-988-2449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4857225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist