Provider Demographics
NPI:1154194892
Name:MENDONCA, KURTIS L (RN)
Entity type:Individual
Prefix:
First Name:KURTIS
Middle Name:L
Last Name:MENDONCA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95963-1958
Mailing Address - Country:US
Mailing Address - Phone:530-591-3486
Mailing Address - Fax:530-591-3486
Practice Address - Street 1:1303 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:ORLAND
Practice Address - State:CA
Practice Address - Zip Code:95963-1958
Practice Address - Country:US
Practice Address - Phone:530-591-3486
Practice Address - Fax:530-591-3486
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95190043163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Single Specialty