Provider Demographics
NPI:1669093977
Name:CARABAJAL, BRENDA L
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:CARABAJAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 ALIF RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-1586
Mailing Address - Country:US
Mailing Address - Phone:505-879-4802
Mailing Address - Fax:
Practice Address - Street 1:200 W SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2530
Practice Address - Country:US
Practice Address - Phone:505-287-5483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM46069163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM616784300OtherDOL PROVIDER NUMBER