Provider Demographics
NPI:1134951239
Name:PALACIOS DE BANDA, LORENA (CCSS, CHW)
Entity type:Individual
Prefix:
First Name:LORENA
Middle Name:
Last Name:PALACIOS DE BANDA
Suffix:
Gender:F
Credentials:CCSS, CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 SAN PEDRO DR NE STE 108
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6744
Mailing Address - Country:US
Mailing Address - Phone:505-209-9230
Mailing Address - Fax:505-273-3115
Practice Address - Street 1:1330 SAN PEDRO DR NE STE 108
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6744
Practice Address - Country:US
Practice Address - Phone:505-209-9230
Practice Address - Fax:505-273-3115
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMG-1326172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker