Healthcare Provider Details

I. General information

NPI: 1811496920
Provider Name (Legal Business Name): MS. KRISTEN M MENDOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2018
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N COOPERS HAWK WAY
PALM COAST FL
32164-2312
US

IV. Provider business mailing address

108 N COOPERS HAWK WAY
PALM COAST FL
32164-2312
US

V. Phone/Fax

Practice location:
  • Phone: 386-717-3566
  • Fax:
Mailing address:
  • Phone: 386-717-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA21338
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: