Healthcare Provider Details

I. General information

NPI: 1710332648
Provider Name (Legal Business Name): BLAIR R MENDOZA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 HIGH ST STE A
BOWLING GREEN KY
42101-1707
US

IV. Provider business mailing address

104 MOHAWK ST
BROWNSVILLE KY
42210-9006
US

V. Phone/Fax

Practice location:
  • Phone: 270-282-7105
  • Fax: 270-282-7109
Mailing address:
  • Phone: 270-597-2155
  • Fax: 270-597-3811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010020
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: