Provider Demographics
NPI:1366816829
Name:RAGAN, MARY KAY (CNP)
Entity Type:Individual
Prefix:
First Name:MARY KAY
Middle Name:
Last Name:RAGAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 NORTH MAIN
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2830
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:575-396-1454
Practice Address - Street 1:310 N. MAIN
Practice Address - Street 2:
Practice Address - City:TATUM
Practice Address - State:NM
Practice Address - Zip Code:88267
Practice Address - Country:US
Practice Address - Phone:575-398-2111
Practice Address - Fax:575-396-1454
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02813363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21701580Medicaid
NM21701580Medicaid