Provider Demographics
NPI:1518207364
Name:SUSSEX-UPHOLD, MANDI KAY (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MANDI
Middle Name:KAY
Last Name:SUSSEX-UPHOLD
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 1:7009 CHRISTY AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3901
Mailing Address - Country:US
Mailing Address - Phone:505-402-3363
Mailing Address - Fax:
Practice Address - Street 1:1005 21ST ST SE STE 4
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4030
Practice Address - Country:US
Practice Address - Phone:505-402-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7209174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist