Provider Demographics
NPI:1871100537
Name:HARRELSON, ADRIENE
Entity type:Individual
Prefix:
First Name:ADRIENE
Middle Name:
Last Name:HARRELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 RODEO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6816
Mailing Address - Country:US
Mailing Address - Phone:505-982-2129
Mailing Address - Fax:
Practice Address - Street 1:1264 RODEO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6816
Practice Address - Country:US
Practice Address - Phone:505-982-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002075858164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse