Provider Demographics
NPI:1477325686
Name:ZEPEDA, CHRISTINE LIZA
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LIZA
Last Name:ZEPEDA
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 1:6417 MESA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-2053
Mailing Address - Country:US
Mailing Address - Phone:817-889-5185
Mailing Address - Fax:
Practice Address - Street 1:6115 CAMP BOWIE BLVD BLDG STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5512
Practice Address - Country:US
Practice Address - Phone:817-889-5185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1130028363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care