Basic Information
| Provider Information | |||||||||
| NPI: | 1720457054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | JEMIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AG ACNP-BC, ACCNS-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MENDOZA | ||||||||
| OtherFirstName: | MARIE | ||||||||
| OtherMiddleName: | JEMIE REYES | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AG ACNP-BC, ACCNS-BC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 221 W COLORADO BLVD | ||||||||
| Address2: | PAVILION II, SUITE 929 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752082363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149411366 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1441 N BECKLEY AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752031201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149478181 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2015 | ||||||||
| LastUpdateDate: | 01/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP129028 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | AP129028 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LC0200X | AP129028 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine | 363LG0600X | AP129028 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 364SA2100X | AP129028 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care | 364S00000X | AP129028 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 364SC0200X | AP129028 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Critical Care Medicine | 364SG0600X | AP129028 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology | 364SA2200X | AP129028 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
No ID Information.