Provider Demographics
NPI:1538495346
Name:HETTLER, MELISSA GAYLE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:GAYLE
Last Name:HETTLER
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 1:3801 WILLIAM D TATE AVE STE 840
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8759
Mailing Address - Country:US
Mailing Address - Phone:817-310-3772
Mailing Address - Fax:817-310-3950
Practice Address - Street 1:3801 WILLIAM D TATE AVE STE 840
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8759
Practice Address - Country:US
Practice Address - Phone:817-310-3772
Practice Address - Fax:817-310-3950
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX723477363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX257745YKPWMedicare PIN