Provider Demographics
NPI:1568140366
Name:DUARTE, MARY LISA (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LISA
Last Name:DUARTE
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LISA
Other - Last Name:TREVINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 MARRIOTT DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-2213
Mailing Address - Country:US
Mailing Address - Phone:361-777-3991
Mailing Address - Fax:
Practice Address - Street 1:614 W FRONT ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-7112
Practice Address - Country:US
Practice Address - Phone:361-664-9587
Practice Address - Fax:361-668-0222
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1055849363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health