=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093292096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELODY LANE MATEJ FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2018
-----------------------------------------------------
Last Update Date | 08/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1413 OATES DR
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-613-7001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 CAMPBELL CT
-----------------------------------------------------
City | FATE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75189-4998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-980-6305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP138189
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------