Healthcare Provider Details

I. General information

NPI: 1225768831
Provider Name (Legal Business Name): IVETTE ARIANA MENDOZA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/23/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13737 TX-36
NEEDVILLE TX
77461
US

IV. Provider business mailing address

5759 WANDERING CREEK DR
RICHMOND TX
77469-6191
US

V. Phone/Fax

Practice location:
  • Phone: 979-793-3940
  • Fax:
Mailing address:
  • Phone: 832-560-1726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1073614
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1073614
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: