Provider Demographics
NPI:1598439374
Name:MENDOZA, NIKI LEE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NIKI
Middle Name:LEE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 KENSINGTON LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-3871
Mailing Address - Country:US
Mailing Address - Phone:630-362-5446
Mailing Address - Fax:
Practice Address - Street 1:1902 JAMES L REDMAN PKWY
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-7101
Practice Address - Country:US
Practice Address - Phone:813-652-8027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT37514225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist