MEDICARE: LAURIE MENDIOLA CNP, PMHNP-BC, FNP-B

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R53580	NM
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	R53580	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962422691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE MENDIOLA CNP, PMHNP-BC, FNP-B

Provider Business Mailing Address
First Line	:	7112 PORTULACA DR NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-2763
Country	:	US
Telephone Number	:	505-553-2278
Fax Number	:	505-508-1569

Provider Business Practice Location Address
First Line	:	3150 CARLISLE BLVD NE STE 108
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-1680
Country	:	US
Telephone Number	:	505-830-6018
Fax Number	:	505-830-6025

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	01/07/2008

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