Provider Demographics
NPI:1376699769
Name:BROCKMAN, MELINDA G (MSN, RN, ACNP)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:G
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:MSN, RN, ACNP
Other - Prefix:MS
Other - First Name:MELINDA
Other - Middle Name:G
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, ACNP
Mailing Address - Street 1:1001 N WALDROP DR STE 509
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-4703
Mailing Address - Country:US
Mailing Address - Phone:817-394-4300
Mailing Address - Fax:817-394-0200
Practice Address - Street 1:1001 N WALDROP DR STE 509
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4703
Practice Address - Country:US
Practice Address - Phone:817-394-4300
Practice Address - Fax:817-394-0200
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX636960363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care