Provider Demographics
NPI:1316597743
Name:DIVER, GRACIELA MELVA (FNP)
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:MELVA
Last Name:DIVER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S PRESTON RD STE 10
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8885
Mailing Address - Country:US
Mailing Address - Phone:469-800-5200
Mailing Address - Fax:469-800-5210
Practice Address - Street 1:111 S PRESTON RD STE 10
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8885
Practice Address - Country:US
Practice Address - Phone:469-800-5200
Practice Address - Fax:469-800-5210
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143036363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily