Provider Demographics
NPI:1508154931
Name:LAUMBACH, MARY M
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:LAUMBACH
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:PO BOX 158
Mailing Address - Street 2:EL CENTRO FAMILY HEALTH
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:555 WAGON MOUND HIGHWAY
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:NM
Practice Address - Zip Code:87743
Practice Address - Country:US
Practice Address - Phone:575-485-2484
Practice Address - Fax:575-485-2261
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP01740363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily