Provider Demographics
NPI:1912606450
Name:MENDOZA, NUBIA
Entity type:Individual
Prefix:
First Name:NUBIA
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 GUY LOMBARDO AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-4915
Mailing Address - Country:US
Mailing Address - Phone:516-519-0467
Mailing Address - Fax:
Practice Address - Street 1:459 E 149TH ST STE 202
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-1789
Practice Address - Country:US
Practice Address - Phone:844-400-1975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY859585-01163WP0808X
NY406664363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health