Healthcare Provider Details

I. General information

NPI: 1174076251
Provider Name (Legal Business Name): MAYRA ALEJANDRA VILLALTA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS MAYRA ALEJANDRA GONZALEZ

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 S BRAESWOOD BLVD SUITE 5330
HOUSTON TX
77030-4444
US

IV. Provider business mailing address

1114 ROBIN ST UNIT C
HOUSTON TX
77019-4655
US

V. Phone/Fax

Practice location:
  • Phone: 832-824-2999
  • Fax:
Mailing address:
  • Phone: 832-287-7102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number755781
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP130563
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: