Provider Demographics
NPI:1104670371
Name:BORDELON, CARISSA ANN (CNS)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANN
Last Name:BORDELON
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:CARRISA
Other - Middle Name:ANN
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNS
Mailing Address - Street 1:PO BOX 860912
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0912
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN659364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist