Provider Demographics
NPI:1790440782
Name:MENDOZA, AMANDA RENEE (MSN, APRN, FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:MSN, APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:973 N MARTHA CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IL
Mailing Address - Zip Code:60953-6079
Mailing Address - Country:US
Mailing Address - Phone:815-867-6242
Mailing Address - Fax:
Practice Address - Street 1:7562 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7840
Practice Address - Country:US
Practice Address - Phone:352-436-4328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11015597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily