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General NPI Number Information
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NPI Number | 1679124697
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Entity Type | Individual
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Provider Name | MELISSA RENA DIMERSON APRN
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Gender | Female
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Dates
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Enumeration Date | 09/20/2019
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Last Update Date | 08/14/2020
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Provider Practice Location Address
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Address Line | 690 S LOOP 336 W STE 140
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City | CONROE
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State | TX
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Zip | 77304-3320
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Country | US
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Telephone | 936-523-7041
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Fax |
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Provider Business Mailing Address
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Address Line | 30202 GLENBORO DR
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City | SPRING
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State | TX
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Zip | 77386-1717
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Country | US
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Telephone | 817-586-6711
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 720241
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP144738
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License Number State | TX
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