{
"Npi": {
"NPI": "1104738996",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "TREJO",
"FirstName": "MELISSA",
"MiddleName": "JANE",
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "TREJO-MARES",
"OtherFirstName": "MELISSA",
"OtherMiddleName": "JANE",
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": "5",
"FirstLineMailingAddress": "201 WHITE WOLF TRL",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BROKEN BOW",
"MailingAddressStateName": "OK",
"MailingAddressPostalCode": "74728-5621",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "580-306-2444",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "411 S CENTRAL AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "IDABEL",
"PracticeLocationAddressStateName": "OK",
"PracticeLocationAddressPostalCode": "74745-6059",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "580-286-5045",
"PracticeLocationAddressFaxNumber": "580-286-5721",
"EnumerationDate": "09/18/2026",
"LastUpdateDate": "09/18/2026",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "171M00000X",
"TaxonomyName": "Case Manager/Care Coordinator",
"LicenseNumber": null,
"LicenseNumberStateCode": "OK",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}