=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023563335
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAE GRACE MENDOZA APN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2016
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3880 SALEM LAKE DR # F
-----------------------------------------------------
City | LONG GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60047-5292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-235-3072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3880 SALEM LAKE DR # F
-----------------------------------------------------
City | LONG GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60047-5292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-235-3072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 041356399
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 209014869
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------