Provider Demographics
NPI:1801669189
Name:MENDES, DEBRA K
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:K
Last Name:MENDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 SUNNY HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-1618
Mailing Address - Country:US
Mailing Address - Phone:707-845-0806
Mailing Address - Fax:
Practice Address - Street 1:2000 SUNNY HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-1618
Practice Address - Country:US
Practice Address - Phone:707-845-0806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1234654172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver