Provider Demographics
NPI:1720457054
Name:MENDOZA, MARIE JEMIE (AG ACNP-BC, ACCNS-BC)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:JEMIE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:AG ACNP-BC, ACCNS-BC
Other - Prefix:MS
Other - First Name:MARIE
Other - Middle Name:JEMIE REYES
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AG ACNP-BC, ACCNS-BC
Mailing Address - Street 1:221 W COLORADO BLVD
Mailing Address - Street 2:PAVILION II, SUITE 929
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2363
Mailing Address - Country:US
Mailing Address - Phone:214-941-1366
Mailing Address - Fax:
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1201
Practice Address - Country:US
Practice Address - Phone:214-947-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129028363L00000X, 363LA2100X, 363LC0200X, 363LG0600X, 364SA2100X, 364S00000X, 364SC0200X, 364SG0600X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health