Provider Demographics
NPI:1093198095
Name:MENDOZA, AMY MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MICHELLE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E LARAMIE ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-2826
Mailing Address - Country:US
Mailing Address - Phone:307-660-2398
Mailing Address - Fax:
Practice Address - Street 1:905 N GURLEY AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-2109
Practice Address - Country:US
Practice Address - Phone:307-686-0669
Practice Address - Fax:307-686-2121
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services