Provider Demographics
NPI:1932329620
Name:WELLS, LISA KATHRYN (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KATHRYN
Last Name:WELLS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 LILLIAN CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-5543
Mailing Address - Country:US
Mailing Address - Phone:505-524-3110
Mailing Address - Fax:
Practice Address - Street 1:ANIMAS PUBLIC SCHOOLS
Practice Address - Street 2:1 PANTHER DR
Practice Address - City:ANIMAS
Practice Address - State:NM
Practice Address - Zip Code:88020
Practice Address - Country:US
Practice Address - Phone:505-548-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1009OtherPHYSICAL THERAPY LISCENSE
NM318597OtherSCHOOL PERSONNEL LISCENSE