Provider Demographics
NPI:1245602127
Name:DALTON, JESSICA (RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DALTON
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 1:538 COUNTY ROAD 6100
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417-9317
Mailing Address - Country:US
Mailing Address - Phone:505-598-6114
Mailing Address - Fax:505-598-9562
Practice Address - Street 1:538 COUNTY ROAD 6100
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:NM
Practice Address - Zip Code:87417-9317
Practice Address - Country:US
Practice Address - Phone:505-598-6114
Practice Address - Fax:505-598-9562
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR66047163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool