Provider Demographics
NPI:1700034832
Name:MONDRAGON, CARRIE ANN (RN)
Entity Type:Individual
Prefix:
First Name:CARRIE ANN
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 1:128 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2290
Mailing Address - Country:US
Mailing Address - Phone:719-587-1038
Mailing Address - Fax:
Practice Address - Street 1:613 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:CO
Practice Address - Zip Code:81152
Practice Address - Country:US
Practice Address - Phone:719-588-2551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO120174163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO74858017Medicaid