Provider Demographics
NPI:1710445945
Name:MEZA, WENDY MARGARITA (STUDENT)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:MARGARITA
Last Name:MEZA
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:M
Other - Last Name:MEZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:STUDENT
Mailing Address - Street 1:11632 130TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-2604
Mailing Address - Country:US
Mailing Address - Phone:917-981-0276
Mailing Address - Fax:
Practice Address - Street 1:2857 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-5126
Practice Address - Country:US
Practice Address - Phone:718-235-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health