Basic Information
Provider Information | |||||||||
NPI: | 1114414430 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOCTOR | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | JOANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DIAZ | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1482 SENDA DEL SOL | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799113045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9158613078 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4849 N MESA ST STE 201 | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799125919 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9153516600 | ||||||||
FaxNumber: | 9153516601 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2018 | ||||||||
LastUpdateDate: | 12/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/09/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 799763 | TX | N |   | Nursing Service Providers | Registered Nurse |   | 363LP0808X | 143585 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 143585 | 01 | TX | TEXAS BOARD ADVANCED PRACTICE PMHNP LICENSE NUMBER | OTHER | 799763 | 01 | TX | TEXAS BOARD OF NURSING LICENSE NUMBER | OTHER |