Provider Demographics
NPI:1649786922
Name:MENDEZ, IEASHIA
Entity type:Individual
Prefix:
First Name:IEASHIA
Middle Name:
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IEASHIA
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:269 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:269 WALKER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4258
Practice Address - Country:US
Practice Address - Phone:404-518-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703118007164W00000X
311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No164W00000XNursing Service ProvidersLicensed Practical Nurse