Healthcare Provider Details

I. General information

NPI: 1912624156
Provider Name (Legal Business Name): ILEY MAE MENDEZ APRN, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 TRINITY WAY
SAINT JOHNS FL
32259-1155
US

IV. Provider business mailing address

300 SAINT ELIZABETH WAY STE 270
SAINT JOHNS FL
32259-1152
US

V. Phone/Fax

Practice location:
  • Phone: 904-691-1000
  • Fax:
Mailing address:
  • Phone: 904-691-9159
  • Fax: 904-691-9159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11036584
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number11036584
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: