Provider Demographics
NPI:1427138833
Name:MELLARD, TANDY ALICE (PNP)
Entity type:Individual
Prefix:MS
First Name:TANDY
Middle Name:ALICE
Last Name:MELLARD
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BARBARA JORDAN BLVD
Mailing Address - Street 2:SUITE #200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3077
Mailing Address - Country:US
Mailing Address - Phone:512-628-1932
Mailing Address - Fax:512-628-1801
Practice Address - Street 1:4900 MUELLER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3079
Practice Address - Country:US
Practice Address - Phone:512-324-0197
Practice Address - Fax:512-324-0780
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6464932080P0203X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176872303Medicaid
TXTXB149308Medicare PIN
Q55348Medicare UPIN