1508912502 NPI number — MELANIE LYNN MENDOZA FNP

Table of content: MELANIE LYNN MENDOZA FNP (NPI 1508912502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508912502 NPI number — MELANIE LYNN MENDOZA FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDOZA
Provider First Name:
MELANIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PAFFORD
Provider Other First Name:
MELANIE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508912502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 E. DOUGLAS BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-593-1721
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CHRISTUS TRINITY CLINIC
Provider Second Line Business Practice Location Address:
520 E. DOUGLAS BLVD.
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-593-1721
Provider Business Practice Location Address Fax Number:
903-525-1259
Provider Enumeration Date:
01/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  912981 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: ARNP 9318647 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 75-2616977-007 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 573360YMAF . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 372757002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8HS129 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".