Provider Demographics
NPI:1679124697
Name:DIMERSON, MELISSA RENA (APRN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENA
Last Name:DIMERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30202 GLENBORO DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-1717
Mailing Address - Country:US
Mailing Address - Phone:817-586-6711
Mailing Address - Fax:
Practice Address - Street 1:690 S LOOP 336 W STE 140
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3320
Practice Address - Country:US
Practice Address - Phone:936-523-7041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX720241163W00000X
TXAP144738363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse