Healthcare Provider Details

I. General information

NPI: 1689442774
Provider Name (Legal Business Name): MARIELA OLMEDO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 S BROADWAY AVE
TYLER TX
75701-4214
US

IV. Provider business mailing address

PO BOX 746079
ATLANTA GA
30374-6079
US

V. Phone/Fax

Practice location:
  • Phone: 903-907-7002
  • Fax: 903-408-6592
Mailing address:
  • Phone: 773-352-1515
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024191232
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF08230579
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: