Healthcare Provider Details

I. General information

NPI: 1912801952
Provider Name (Legal Business Name): DEVINA NADINE MENDOZA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19577 STOWE WAY
CALDWELL ID
83605-1231
US

IV. Provider business mailing address

19577 STOWE WAY
CALDWELL ID
83605-1231
US

V. Phone/Fax

Practice location:
  • Phone: 208-985-3290
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71583
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: