Provider Demographics
NPI:1124435052
Name:SPAN, MERILYN
Entity type:Individual
Prefix:MRS
First Name:MERILYN
Middle Name:
Last Name:SPAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 S MAIN
Mailing Address - Street 2:SUITE 350
Mailing Address - City:FORT
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-321-5450
Mailing Address - Fax:817-321-5451
Practice Address - Street 1:1101 S MAIN ST
Practice Address - Street 2:SUITE 1350
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4802
Practice Address - Country:US
Practice Address - Phone:817-321-5450
Practice Address - Fax:817-321-5451
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105667164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse