Provider Demographics
NPI:1740943505
Name:MONDRAGON, PAULINE SARA (APRN-CNP)
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:SARA
Last Name:MONDRAGON
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CERRADO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-8253
Mailing Address - Country:US
Mailing Address - Phone:505-399-0106
Mailing Address - Fax:
Practice Address - Street 1:12 CERRADO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-8253
Practice Address - Country:US
Practice Address - Phone:505-399-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM65312363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health