Provider Demographics
NPI:1629522529
Name:MENDOZA, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
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 1:1617 W BENBOW ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3414
Mailing Address - Country:US
Mailing Address - Phone:909-582-5021
Mailing Address - Fax:
Practice Address - Street 1:4959 PALO VERDE ST
Practice Address - Street 2:#206A-4
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2331
Practice Address - Country:US
Practice Address - Phone:909-582-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 542569163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health