Provider Demographics
NPI:1023067659
Name:HARRELL, LORENE L
Entity type:Individual
Prefix:
First Name:LORENE
Middle Name:L
Last Name:HARRELL
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 1:2889 PINE FOREST DR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-7281
Mailing Address - Country:US
Mailing Address - Phone:505-994-0409
Mailing Address - Fax:505-994-1472
Practice Address - Street 1:2704 SOUTHERN BLVD SE STE 2
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3748
Practice Address - Country:US
Practice Address - Phone:505-268-1830
Practice Address - Fax:505-994-1472
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM06000069201744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0891260001Medicare ID - Type Unspecified