Provider Demographics
NPI:1487373544
Name:MENDIETTA, MICAELA ANGELA
Entity type:Individual
Prefix:
First Name:MICAELA
Middle Name:ANGELA
Last Name:MENDIETTA
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 1:402 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:TX
Mailing Address - Zip Code:78343-2650
Mailing Address - Country:US
Mailing Address - Phone:361-355-6971
Mailing Address - Fax:
Practice Address - Street 1:410 N PALAFOX ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-3919
Practice Address - Country:US
Practice Address - Phone:850-458-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
TX1367179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist