Provider Demographics
NPI:1275034100
Name:MELLADO, IZELA
Entity Type:Individual
Prefix:
First Name:IZELA
Middle Name:
Last Name:MELLADO
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 1:1619 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-8401
Mailing Address - Country:US
Mailing Address - Phone:282-857-2738
Mailing Address - Fax:
Practice Address - Street 1:1619 AVENUE C
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-8401
Practice Address - Country:US
Practice Address - Phone:282-857-2738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2135966225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant