Provider Demographics
NPI:1497269146
Name:MONDRAGON, CLARISSA (RN)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:MONDRAGON
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 1:21342 US HIGHWAY 84
Mailing Address - Street 2:
Mailing Address - City:ABIQUIU
Mailing Address - State:NM
Mailing Address - Zip Code:87510-2200
Mailing Address - Country:US
Mailing Address - Phone:505-685-4457
Mailing Address - Fax:505-685-4644
Practice Address - Street 1:21342 US HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:ABIQUIU
Practice Address - State:NM
Practice Address - Zip Code:87510-2200
Practice Address - Country:US
Practice Address - Phone:505-685-4457
Practice Address - Fax:505-685-4644
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR52804163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool