MEDICARE: DEXIE MALLARI VILLANUEVA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	964768	TX

General Provider Information

NPI Number	:	1134682420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEXIE MALLARI VILLANUEVA

Provider Business Mailing Address
First Line	:	5520 GRAYSON RIDGE DR
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76179-7113
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5520 GRAYSON RIDGE DR
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76179-7113
Country	:	US
Telephone Number	:	305-340-1424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2019
Last Update Date	:	04/12/2019

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Directions to “ DEXIE MALLARI VILLANUEVA ” Practice Location

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