Provider Demographics
NPI:1174076251
Name:VILLALTA, MAYRA ALEJANDRA (FNP)
Entity type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:ALEJANDRA
Last Name:VILLALTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:MAYRA
Other - Middle Name:ALEJANDRA
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1114 ROBIN ST
Mailing Address - Street 2:UNIT C
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-4655
Mailing Address - Country:US
Mailing Address - Phone:832-287-7102
Mailing Address - Fax:
Practice Address - Street 1:1919 S BRAESWOOD BLVD
Practice Address - Street 2:SUITE 5330
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4444
Practice Address - Country:US
Practice Address - Phone:832-824-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX755781163W00000X
TXAP130563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse