Provider Demographics
NPI:1114414430
Name:DOCTOR, MELISSA JOANN (PMHNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JOANN
Last Name:DOCTOR
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:J
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1482 SENDA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79911-3045
Mailing Address - Country:US
Mailing Address - Phone:915-861-3078
Mailing Address - Fax:
Practice Address - Street 1:4849 N MESA ST STE 201
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-5919
Practice Address - Country:US
Practice Address - Phone:915-351-6600
Practice Address - Fax:915-351-6601
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX799763163W00000X
TX143585363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143585OtherTEXAS BOARD ADVANCED PRACTICE PMHNP LICENSE NUMBER
TX799763OtherTEXAS BOARD OF NURSING LICENSE NUMBER