MEDICARE: MELISSA PRIDEMORE FNP-C

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	363LF0000X	Family Nurse Practitioner	644082	TX

General Provider Information

NPI Number	:	1962747840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA PRIDEMORE FNP-C

Provider Business Mailing Address
First Line	:	7313 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-6616
Country	:	US
Telephone Number	:	817-945-2277
Fax Number	:	817-439-9713

Provider Business Practice Location Address
First Line	:	7313 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-6616
Country	:	US
Telephone Number	:	817-945-2277
Fax Number	:	817-439-9713

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

Provider Enumeration Date	:	12/04/2012
Last Update Date	:	04/08/2016

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