Provider Demographics
NPI:1871707380
Name:MENDOZA, CONSORCIA S
Entity type:Individual
Prefix:MS
First Name:CONSORCIA
Middle Name:S
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 1:2248 ALBRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-1403
Mailing Address - Country:US
Mailing Address - Phone:727-482-0672
Mailing Address - Fax:727-726-1284
Practice Address - Street 1:2248 ALBRIGHT DR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-1403
Practice Address - Country:US
Practice Address - Phone:727-482-0672
Practice Address - Fax:727-726-1284
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7283310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility