Provider Demographics
NPI:1316609449
Name:SANTOS MENDEZ, GRACIELA
Entity type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:SANTOS MENDEZ
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:A18 CALLE PALMA REAL
Mailing Address - Street 2:VILLAS DE SAGRADO CORAZON
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-408-8257
Mailing Address - Fax:
Practice Address - Street 1:A18 CALLE PALMA REAL
Practice Address - Street 2:VILLAS DE SAGRADO CORAZON
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716
Practice Address - Country:US
Practice Address - Phone:787-408-8257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL36013390200000X
PR2212390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2212OtherINTERN CERTIFICATE
FL36013OtherINTERN CERTIFICATE