Healthcare Provider Details

I. General information

NPI: 1083384200
Provider Name (Legal Business Name): AMY MENDOZA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2021
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12955 SW 112TH ST
MIAMI FL
33186-4768
US

IV. Provider business mailing address

12955 SW 112TH ST
MIAMI FL
33186-4768
US

V. Phone/Fax

Practice location:
  • Phone: 305-382-4161
  • Fax:
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11015462
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: