Healthcare Provider Details

I. General information

NPI: 1104785542
Provider Name (Legal Business Name): KIMBERLY MONDRAGON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2026
Last Update Date: 01/21/2026
Certification Date: 01/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 COWBOY WAY
EDGEWOOD NM
87015-9616
US

IV. Provider business mailing address

10 AVENIDA PITA
SANTA FE NM
87505-1482
US

V. Phone/Fax

Practice location:
  • Phone: 505-750-2707
  • Fax:
Mailing address:
  • Phone: 505-750-2707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCTB-2025-0948
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: