MEDICARE: VICKY MULENDELA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1124982400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKY MULENDELA

Provider Business Mailing Address
First Line	:	4175 S LEANING TOWER AVE
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-5242
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9428 W FAIRVIEW AVE
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8101
Country	:	US
Telephone Number	:	208-807-4970
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2025
Last Update Date	:	03/02/2026

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Directions to “ VICKY MULENDELA ” Practice Location

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