Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | 1013656 | TX |
NPI | 1033710074 |
---|---|
Provider Name | Brooke Mendiola |
First Address | Portland, TX 78374-3202 |
Second Address | San Antonio, TX 78251-2889 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/11/2020 |
Last Update Date | 05/11/2020 |