Provider Demographics
NPI:1093045684
Name:HARRIS, MENDALOSE ORTEGA (RN)
Entity Type:Individual
Prefix:
First Name:MENDALOSE
Middle Name:ORTEGA
Last Name:HARRIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38701 38TH ST
Mailing Address - Street 2:PREVENTATIVE MEDICINE BUILDING
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:706-787-1193
Mailing Address - Fax:
Practice Address - Street 1:300 EAST HOSPITAL ROAD
Practice Address - Street 2:DWIGHT DAVID EISENHOWER ARMY MEDICAL CENTER
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5650
Practice Address - Country:US
Practice Address - Phone:706-787-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041257023163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041257023OtherARMY PUBLIC HEALTH NURSE-MILITARY PROVIDER