MEDICARE: MELISSA CHAVIRA DE LA VEGA PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	797788	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	287585802	OTHER	TX	CSHCN

General Provider Information

NPI Number	:	1376829051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA CHAVIRA DE LA VEGA PMHNP

Provider Business Mailing Address
First Line	:	PO BOX 99371
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76199-0371
Country	:	US
Telephone Number	:	682-885-1855
Fax Number	:	682-885-7347

Provider Business Practice Location Address
First Line	:	1300 S UNIVERSITY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-5737
Country	:	US
Telephone Number	:	682-885-1050
Fax Number	:	682-885-7572

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2011
Last Update Date	:	04/03/2012

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