Provider Demographics
NPI:1033940788
Name:MENDOZA, EDITH
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EDITH
Other - Middle Name:
Other - Last Name:MENDOZA CORONEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 W MARLAND CT
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-2740
Mailing Address - Country:US
Mailing Address - Phone:315-263-8223
Mailing Address - Fax:
Practice Address - Street 1:700 JOHN RINGLING BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-1542
Practice Address - Country:US
Practice Address - Phone:941-365-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA17942224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant