Provider Demographics
NPI:1194315226
Name:BLANCO, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 32ND CIR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1914
Mailing Address - Country:US
Mailing Address - Phone:505-433-9007
Mailing Address - Fax:
Practice Address - Street 1:1540 32ND CIR SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1914
Practice Address - Country:US
Practice Address - Phone:505-433-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT9386225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist