=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184357188
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIELLA MENDEZ WILSON FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2022
-----------------------------------------------------
Last Update Date | 05/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6095 N 1ST ST
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-5444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-446-1515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9807 E BULLARD AVE
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93619-8202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-260-9339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95021553
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------