Healthcare Provider Details

I. General information

NPI: 1013780980
Provider Name (Legal Business Name): MELANIE JILL BEBOUT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 GOODMAN AVE APT 3304
ADDISON TX
75001-6627
US

IV. Provider business mailing address

4940 GOODMAN AVE APT 3304
ADDISON TX
75001-6627
US

V. Phone/Fax

Practice location:
  • Phone: 806-626-8014
  • Fax:
Mailing address:
  • Phone: 806-626-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1140598
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: