Provider Demographics
NPI:1730691742
Name:BALDONADO, LARISSA (RN)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:BALDONADO
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 1:1700 TESORO LOOP NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8963
Mailing Address - Country:US
Mailing Address - Phone:505-720-5212
Mailing Address - Fax:
Practice Address - Street 1:1202 MAIN ST NE STE A
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7421
Practice Address - Country:US
Practice Address - Phone:505-565-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-82564163WC1500X
NM78581363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health