Provider Demographics
NPI:1336374172
Name:MCDANIEL, DIANE VALLEJOS (LMT 5069)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:VALLEJOS
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:LMT 5069
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:VALLEJOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT 5069
Mailing Address - Street 1:6827 GLACIER RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3756
Mailing Address - Country:US
Mailing Address - Phone:505-315-6328
Mailing Address - Fax:
Practice Address - Street 1:6827 GLACIER RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-3756
Practice Address - Country:US
Practice Address - Phone:505-315-6328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5069173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist