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General NPI Number Information
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NPI Number | 1689306490
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Entity Type | Individual
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Provider Name | FANNIELYN MENDOZA
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Gender | Female
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Dates
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Enumeration Date | 06/29/2022
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Last Update Date | 06/29/2022
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Provider Practice Location Address
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Address Line | 1510 CHEYENNE TRL
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City | MANSFIELD
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State | TX
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Zip | 76063-7955
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Country | US
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Telephone | 415-870-5990
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Fax |
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Provider Business Mailing Address
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Address Line | 1510 CHEYENNE TRL
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City | MANSFIELD
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State | TX
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Zip | 76063-7955
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Country | US
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Telephone | 415-870-5990
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 212074
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License Number State | TX
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