Provider Demographics
NPI:1477077782
Name:WILDFLOWER, LEA (CMP)
Entity type:Individual
Prefix:MS
First Name:LEA
Middle Name:
Last Name:WILDFLOWER
Suffix:
Gender:F
Credentials:CMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 CALLE MEJIA APT 511
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1464
Mailing Address - Country:US
Mailing Address - Phone:415-320-3819
Mailing Address - Fax:
Practice Address - Street 1:500 RODEO RD RM 4
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6378
Practice Address - Country:US
Practice Address - Phone:415-320-3819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22150225700000X
NM2024-0172225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22150OtherCAMTC
NMMT20240172OtherSTATE