Provider Demographics
NPI:1821653254
Name:MENDIVE, KAMYLLI (PA-C)
Entity Type:Individual
Prefix:
First Name:KAMYLLI
Middle Name:
Last Name:MENDIVE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 HIGH SCHOOL AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1858
Mailing Address - Country:US
Mailing Address - Phone:925-687-5210
Mailing Address - Fax:
Practice Address - Street 1:2415 HIGH SCHOOL AVE STE 800
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1858
Practice Address - Country:US
Practice Address - Phone:925-687-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant