Provider Demographics
NPI:1689144677
Name:MENDOZA, AMBAR ALEHLY
Entity Type:Individual
Prefix:
First Name:AMBAR
Middle Name:ALEHLY
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 1:1528 ASH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-3308
Mailing Address - Country:US
Mailing Address - Phone:805-478-5460
Mailing Address - Fax:
Practice Address - Street 1:301 N R ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-5226
Practice Address - Country:US
Practice Address - Phone:805-737-6071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86076955133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered