Provider Demographics
NPI:1003697400
Name:MENDEZ, STEPHANIE (RDN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 VISTA VIEW PL
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-4728
Mailing Address - Country:US
Mailing Address - Phone:562-964-2113
Mailing Address - Fax:
Practice Address - Street 1:140 VISTA VIEW PL
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4728
Practice Address - Country:US
Practice Address - Phone:562-964-2113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86328749133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered