Healthcare Provider Details

I. General information

NPI: 1720918899
Provider Name (Legal Business Name): EDLISSE JOMARY MENDOZA MORALES APRN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 CALLE PRUNA
SAN JUAN PR
00923-2122
US

IV. Provider business mailing address

531 CALLE PRUNA
SAN JUAN PR
00923-2122
US

V. Phone/Fax

Practice location:
  • Phone: 787-518-1956
  • Fax:
Mailing address:
  • Phone: 787-518-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number005959
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11034870
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: