Healthcare Provider Details

I. General information

NPI: 1932854254
Provider Name (Legal Business Name): MARY JACQUELINE VALLESTEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 N YORK ST
HOUSTON TX
77003-1752
US

IV. Provider business mailing address

9225 MONSEY DR
HOUSTON TX
77063-4063
US

V. Phone/Fax

Practice location:
  • Phone: 713-652-3145
  • Fax:
Mailing address:
  • Phone: 281-925-8943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1058913
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: