Provider Demographics
NPI:1740386549
Name:GRIJALVA, MELINDA DOLORES (CPNP)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:DOLORES
Last Name:GRIJALVA
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 N VETERANS BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-4456
Mailing Address - Country:US
Mailing Address - Phone:830-773-9449
Mailing Address - Fax:830-757-3142
Practice Address - Street 1:1975 N VETERANS BLVD STE 5
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-4456
Practice Address - Country:US
Practice Address - Phone:830-773-9449
Practice Address - Fax:830-757-3142
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230790363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N3345OtherBC/BS INDIVIDUAL NUMBER
TX230790OtherRN
TX00241UMedicare ID - Type UnspecifiedMEDICARE GROUP #