MEDICARE: MRS. KIMBERLY LYNN MENDOZA PA-C

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	363A00000X	Physician Assistant	PA9114084	FL
2	225X00000X	Occupational Therapist	23539	FL

General Provider Information

NPI Number	:	1174649933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY LYNN MENDOZA PA-C

Provider Business Mailing Address
First Line	:	50 GOSSAMER LN UNIT 7
Second Line	:
City	:	INLET BEACH
State	:	FL
Zip	:	32461-7051
Country	:	US
Telephone Number	:	703-964-7838
Fax Number	:

Provider Business Practice Location Address
First Line	:	2011 HARRISON AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4545
Country	:	US
Telephone Number	:	850-691-4188
Fax Number	:	833-687-1451

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	10/20/2022

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