Healthcare Provider Details

I. General information

NPI: 1730691742
Provider Name (Legal Business Name): LARISSA BALDONADO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SANDOVAL RD SW
LOS LUNAS NM
87031-7320
US

IV. Provider business mailing address

1700 TESORO LOOP NW
LOS LUNAS NM
87031-8963
US

V. Phone/Fax

Practice location:
  • Phone: 505-631-0019
  • Fax: 505-631-0020
Mailing address:
  • Phone: 505-631-0019
  • Fax: 505-631-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number78581
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN-82564
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: