MEDICARE: LACOSTA MENDOZA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WM0705X	Medical-Surgical Registered Nurse	RN.461738	OH

General Provider Information

NPI Number	:	1912755133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACOSTA MENDOZA

Provider Business Mailing Address
First Line	:	208 WASSENBERG DR
Second Line	:
City	:	VAN WERT
State	:	OH
Zip	:	45891-2358
Country	:	US
Telephone Number	:	260-416-4223
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 WASSENBERG DR
Second Line	:
City	:	VAN WERT
State	:	OH
Zip	:	45891-2358
Country	:	US
Telephone Number	:	260-416-4223
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2024
Last Update Date	:	05/13/2024

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Directions to “ LACOSTA MENDOZA ” Practice Location

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