MEDICARE: AMANDA MENDEZ NP

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	363LF0000X	Family Nurse Practitioner	668519	TX
2	363LF0000X	Family Nurse Practitioner	AP115630	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	668519	OTHER	TX	TX NP LICENSE

General Provider Information

NPI Number	:	1487780540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MENDEZ NP

Provider Business Mailing Address
First Line	:	PO BOX 732973
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75373-2973
Country	:	US
Telephone Number	:	817-702-8450
Fax Number	:

Provider Business Practice Location Address
First Line	:	2011 PROSPECT AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164-8260
Country	:	US
Telephone Number	:	817-702-4871
Fax Number	:	817-625-7443

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

Provider Enumeration Date	:	02/25/2007
Last Update Date	:	12/06/2018

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