Provider Demographics
NPI:1720713969
Name:MENDOZA, EDITH MARIE (NP)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:MARIE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 E SOUTHLAKE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6687
Mailing Address - Country:US
Mailing Address - Phone:817-873-0590
Mailing Address - Fax:817-873-0591
Practice Address - Street 1:2485 E SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6687
Practice Address - Country:US
Practice Address - Phone:817-873-0590
Practice Address - Fax:817-873-0591
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP1088173363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP1088173OtherAPRN
TX630874OtherRN