Provider Demographics
NPI:1245790914
Name:MOMBELEUR, FARIDY MAYA
Entity Type:Individual
Prefix:
First Name:FARIDY
Middle Name:MAYA
Last Name:MOMBELEUR
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 1:1816 S FM 51 STE 400
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3788
Mailing Address - Country:US
Mailing Address - Phone:940-626-1848
Mailing Address - Fax:940-626-1849
Practice Address - Street 1:2000 S FM 51 STE C
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3702
Practice Address - Country:US
Practice Address - Phone:940-626-1848
Practice Address - Fax:940-626-1849
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140998363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGOtherBCBSTX
TXPENDINGMedicaid