Provider Demographics
NPI:1710332648
Name:MENDOZA, BLAIR R (APRN)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:R
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42210-9006
Mailing Address - Country:US
Mailing Address - Phone:270-597-2155
Mailing Address - Fax:270-597-3811
Practice Address - Street 1:440 HIGH ST
Practice Address - Street 2:STE A
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1707
Practice Address - Country:US
Practice Address - Phone:270-282-7105
Practice Address - Fax:270-282-7109
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3010020363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily