Provider Demographics
NPI:1376829051
Name:DE LA VEGA, MELISSA CHAVIRA (PMHNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:CHAVIRA
Last Name:DE LA VEGA
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:CHAVIRA-DE LA VEGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP
Mailing Address - Street 1:PO BOX 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:1300 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5737
Practice Address - Country:US
Practice Address - Phone:682-885-1050
Practice Address - Fax:682-885-7572
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX797788363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287585801Medicaid
TX287585802OtherCSHCN
TX287585802OtherCSHCN