Provider Demographics
NPI:1609104066
Name:DE LEON, MARY OLIVIA (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:OLIVIA
Last Name:DE LEON
Suffix:
Gender:F
Credentials:FNP
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Other - Credentials:
Mailing Address - Street 1:1474 W. PRICE RD
Mailing Address - Street 2:STE 7 BOX 536
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8675
Mailing Address - Country:US
Mailing Address - Phone:956-350-5530
Mailing Address - Fax:956-350-5527
Practice Address - Street 1:4920 N. EXPRESSWAY,
Practice Address - Street 2:ALTON GLOOR PLAZA#101
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526
Practice Address - Country:US
Practice Address - Phone:956-350-5530
Practice Address - Fax:956-350-5527
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX670508364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1336125046Medicaid