Basic Information
| Provider Information | |||||||||
| NPI: | 1558935544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | VENCES | ||||||||
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| Credential: | CRM, NCMA, TSH, PSS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10209 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972661372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037197609 | ||||||||
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| Practice Location | |||||||||
| Address1: | 971 SW WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971235651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036405297 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2021 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.