Provider Demographics
NPI:1730554718
Name:SPURLOCK-MONDRAGON, HEIDI (LPN)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:SPURLOCK-MONDRAGON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 STATE HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:KRAKOW
Mailing Address - State:WI
Mailing Address - Zip Code:54137-9729
Mailing Address - Country:US
Mailing Address - Phone:920-655-8666
Mailing Address - Fax:
Practice Address - Street 1:2270 STATE HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:KRAKOW
Practice Address - State:WI
Practice Address - Zip Code:54137-9729
Practice Address - Country:US
Practice Address - Phone:920-655-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI319384164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse