Provider Demographics
NPI:1962015958
Name:BELLISARIO, EUN (CNP)
Entity Type:Individual
Prefix:
First Name:EUN
Middle Name:
Last Name:BELLISARIO
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 1:1217 BONITA ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2103
Mailing Address - Country:US
Mailing Address - Phone:505-287-2958
Mailing Address - Fax:
Practice Address - Street 1:1217 BONITA ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2103
Practice Address - Country:US
Practice Address - Phone:505-287-2958
Practice Address - Fax:505-287-2403
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008838363L00000X
NM61906363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner