Healthcare Provider Details

I. General information

NPI: 1164102869
Provider Name (Legal Business Name): SUSSETTI MARILU DE PENA MENDEZ SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 ROAD 5706
CLEVELAND TX
77327
US

IV. Provider business mailing address

945 ROAD 5706
CLEVELAND TX
77327
US

V. Phone/Fax

Practice location:
  • Phone: 346-789-4364
  • Fax:
Mailing address:
  • Phone: 346-789-4364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number23-425
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: