Provider Demographics
NPI:1154420545
Name:KHALSA, LORENA PAOLA (LMT)
Entity type:Individual
Prefix:MRS
First Name:LORENA
Middle Name:PAOLA
Last Name:KHALSA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1421
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:NM
Mailing Address - Zip Code:87567-1421
Mailing Address - Country:US
Mailing Address - Phone:505-753-0298
Mailing Address - Fax:
Practice Address - Street 1:415 N PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2619
Practice Address - Country:US
Practice Address - Phone:505-753-3369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4841225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist