Provider Demographics
NPI:1366659161
Name:MENDOZA, SELENE (CNP)
Entity Type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 MALL DR STE C
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8193
Mailing Address - Country:US
Mailing Address - Phone:575-522-2330
Mailing Address - Fax:575-522-2344
Practice Address - Street 1:1161 MALL DR
Practice Address - Street 2:STE. C
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8193
Practice Address - Country:US
Practice Address - Phone:575-522-2330
Practice Address - Fax:575-522-2344
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP01102163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45401837Medicaid