Provider Demographics
NPI:1538830633
Name:MENDOZA, KENNETTE
Entity type:Individual
Prefix:
First Name:KENNETTE
Middle Name:
Last Name:MENDOZA
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 1:3460 SARATOGA AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1348
Mailing Address - Country:US
Mailing Address - Phone:630-971-1995
Mailing Address - Fax:
Practice Address - Street 1:3460 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1348
Practice Address - Country:US
Practice Address - Phone:630-971-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043108931164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse