Provider Demographics
NPI:1467929083
Name:MENDIETTA, TARA (FNPC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MENDIETTA
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78333-0289
Mailing Address - Country:US
Mailing Address - Phone:361-664-9353
Mailing Address - Fax:361-668-1630
Practice Address - Street 1:305 E 3RD ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4705
Practice Address - Country:US
Practice Address - Phone:361-664-9353
Practice Address - Fax:361-668-1630
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139592363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily