Provider Demographics
NPI:1679043459
Name:SMITH, MELISSA ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ELIZABETH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MANZANO, MATTHEWS
Mailing Address - Street 1:3813 KELVIN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-2947
Mailing Address - Country:US
Mailing Address - Phone:972-567-7881
Mailing Address - Fax:
Practice Address - Street 1:9108 CAMP BOWIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-6098
Practice Address - Country:US
Practice Address - Phone:682-356-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141462363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty