Provider Demographics
NPI: | 1376829051 |
---|---|
Name: | DE LA VEGA, MELISSA CHAVIRA (PMHNP) |
Entity Type: | Individual |
Prefix: | |
First Name: | MELISSA |
Middle Name: | CHAVIRA |
Last Name: | DE LA VEGA |
Suffix: | |
Gender: | F |
Credentials: | PMHNP |
Other - Prefix: | |
Other - First Name: | MELISSA |
Other - Middle Name: | |
Other - Last Name: | CHAVIRA-DE LA VEGA |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | PMHNP |
Mailing Address - Street 1: | PO BOX 99371 |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT WORTH |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 76199-0371 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 682-885-1855 |
Mailing Address - Fax: | 682-885-7347 |
Practice Address - Street 1: | 1300 S UNIVERSITY DR |
Practice Address - Street 2: | |
Practice Address - City: | FORT WORTH |
Practice Address - State: | TX |
Practice Address - Zip Code: | 76107-5737 |
Practice Address - Country: | US |
Practice Address - Phone: | 682-885-1050 |
Practice Address - Fax: | 682-885-7572 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-10-26 |
Last Update Date: | 2012-04-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 797788 | 363LP0808X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 287585801 | Medicaid | |
TX | 287585802 | Other | CSHCN |
TX | 287585802 | Other | CSHCN |