Provider Demographics
NPI:1598521692
Name:IBARRA MONTANEZ, BLANCA YASMIN
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:YASMIN
Last Name:IBARRA MONTANEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BLANCA
Other - Middle Name:YASMIN
Other - Last Name:LOPEZ PERDOMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:51615 ZUNI CIR APT 4
Mailing Address - Street 2:
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544-2145
Mailing Address - Country:US
Mailing Address - Phone:254-402-6200
Mailing Address - Fax:
Practice Address - Street 1:51615 ZUNI CIR APT 4
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544-2145
Practice Address - Country:US
Practice Address - Phone:254-402-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44157874172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver