Provider Demographics
NPI:1336750231
Name:JIMENEZ MENDOZA, LINA MARIA (LPN)
Entity Type:Individual
Prefix:
First Name:LINA
Middle Name:MARIA
Last Name:JIMENEZ MENDOZA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:LINA
Other - Middle Name:M
Other - Last Name:JIMENEZ MENDOZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1009 76TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4913
Mailing Address - Country:US
Mailing Address - Phone:201-344-9537
Mailing Address - Fax:
Practice Address - Street 1:1009 76TH ST
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4913
Practice Address - Country:US
Practice Address - Phone:201-344-9537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJDCATEMP-018577164W00000X
NY338159164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty