Provider Demographics
NPI:1427288968
Name:MOURAD, CAROLYN DIANE P (RN)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DIANE P
Last Name:MOURAD
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 1:1976 CORTA RUSTICA RD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7507
Mailing Address - Country:US
Mailing Address - Phone:505-865-9842
Mailing Address - Fax:
Practice Address - Street 1:1976 CORTA RUSTICA RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7507
Practice Address - Country:US
Practice Address - Phone:505-865-9842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR26250163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR26250OtherREGISTERED NURSE, NEW MEXICO LICENSE
NMR26250OtherRN LICENSE