Provider Demographics
NPI:1124044029
Name:LEVEILLE, MARYGRACE C (NP)
Entity Type:Individual
Prefix:
First Name:MARYGRACE
Middle Name:C
Last Name:LEVEILLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 LYNDON B JOHNSON FWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3405
Mailing Address - Country:US
Mailing Address - Phone:972-739-3097
Mailing Address - Fax:972-739-2673
Practice Address - Street 1:4360 N JOSEY LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4602
Practice Address - Country:US
Practice Address - Phone:972-939-8294
Practice Address - Fax:214-731-0240
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX533547363L00000X
TXAP109451363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175724702Medicaid
TX175724701Medicaid
TXS89015Medicare UPIN