Healthcare Provider Details

I. General information

NPI: 1255963468
Provider Name (Legal Business Name): MELANIE MARIE VAGUE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE MARIE HOLLAR

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S 31ST ST
TEMPLE TX
76508-2401
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 254-724-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberAP145826
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number879568
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: