Provider Demographics
NPI:1477188308
Name:CAMACHO, MARIA DE LOURDES
Entity Type:Individual
Prefix:MISS
First Name:MARIA
Middle Name:DE LOURDES
Last Name:CAMACHO
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 1:5215 AUDREY ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75210-3202
Mailing Address - Country:US
Mailing Address - Phone:972-679-7942
Mailing Address - Fax:
Practice Address - Street 1:3701 W NORTHWEST HWY STE 189
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-4972
Practice Address - Country:US
Practice Address - Phone:972-679-7942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33828363LF0000X
TXAP145529363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily