Provider Demographics
NPI:1043599202
Name:MENDOZA, LAURA I (CPNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:I
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 BENEDICT AVE
Mailing Address - Street 2:STE B
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-2712
Mailing Address - Country:US
Mailing Address - Phone:419-668-9409
Mailing Address - Fax:419-668-7099
Practice Address - Street 1:282 BENEDICT AVE
Practice Address - Street 2:STE B
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2712
Practice Address - Country:US
Practice Address - Phone:419-668-9409
Practice Address - Fax:419-668-7099
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12451-NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0053752Medicaid