Provider Demographics
NPI:1578061628
Name:LOMAX, NICOLE J
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:LOMAX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:JUNE
Other - Last Name:STANFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:412 S AVENUE F APT 304
Mailing Address - Street 2:
Mailing Address - City:TEXICO
Mailing Address - State:NM
Mailing Address - Zip Code:88135-9663
Mailing Address - Country:US
Mailing Address - Phone:432-889-0692
Mailing Address - Fax:
Practice Address - Street 1:1500 S AVENUE K
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-7400
Practice Address - Country:US
Practice Address - Phone:575-562-4232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3293011Medicaid