Healthcare Provider Details

I. General information

NPI: 1588649370
Provider Name (Legal Business Name): MELYNDA GAYE DENNIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 82ND ST
LUBBOCK TX
79423-1429
US

IV. Provider business mailing address

5219 CITY BANK PKWY SUITE 135
LUBBOCK TX
79407-3544
US

V. Phone/Fax

Practice location:
  • Phone: 806-761-0428
  • Fax: 806-712-0168
Mailing address:
  • Phone: 806-761-0334
  • Fax: 806-722-2908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001657
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01477
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: