Healthcare Provider Details

I. General information

NPI: 1174090781
Provider Name (Legal Business Name): MELISSA LARAE DISHMAN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 N MACARTHUR BLVD SUITE 500
IRVING TX
75062-7573
US

IV. Provider business mailing address

3501 N MACARTHUR BLVD SUITE 500
IRVING TX
75062
US

V. Phone/Fax

Practice location:
  • Phone: 972-256-3700
  • Fax: 866-630-6348
Mailing address:
  • Phone: 972-256-3700
  • Fax: 866-630-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP139412
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: