Provider Demographics
NPI:1003045204
Name:MEDALIE, AMY MICHELLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MICHELLE
Last Name:MEDALIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:MEDALIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:
Practice Address - Street 1:4405 RIVER OAKS BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-2326
Practice Address - Country:US
Practice Address - Phone:817-624-1770
Practice Address - Fax:817-625-1287
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6037363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics