Provider Demographics
NPI:1689740656
Name:MESOBELLA
Entity Type:Organization
Organization Name:MESOBELLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANZA
Authorized Official - Suffix:
Authorized Official - Credentials:RN,WOCN,MSN,FNP
Authorized Official - Phone:817-291-5780
Mailing Address - Street 1:731 E SOUTHLAKE BLVD # 180
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6377
Mailing Address - Country:US
Mailing Address - Phone:817-251-6376
Mailing Address - Fax:
Practice Address - Street 1:731 E SOUTHLAKE BLVD # 180
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6377
Practice Address - Country:US
Practice Address - Phone:817-251-6376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX583243363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ57338Medicare UPIN
TX00W172Medicare ID - Type UnspecifiedBUSINESS NUMBER