Provider Demographics
NPI:1548591159
Name:MENDIETA, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MENDIETA
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 1:15802 N PARKVIEW PL
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7466
Mailing Address - Country:US
Mailing Address - Phone:623-523-8750
Mailing Address - Fax:
Practice Address - Street 1:15802 N PARKVIEW PL
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7466
Practice Address - Country:US
Practice Address - Phone:623-523-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP047649164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse