Provider Demographics
NPI:1730370172
Name:MORDUE-LAIN, DENISE AUDREY (NP)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:AUDREY
Last Name:MORDUE-LAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:AUDREY
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1919 VISTA DEL LAGO DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95252-9294
Mailing Address - Country:US
Mailing Address - Phone:209-772-9538
Mailing Address - Fax:209-772-0312
Practice Address - Street 1:1919 VISTA DEL LAGO DR
Practice Address - Street 2:
Practice Address - City:VALLEY SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95252-9294
Practice Address - Country:US
Practice Address - Phone:209-772-9538
Practice Address - Fax:209-772-0312
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP6294163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory