1053645697 NPI number — MRS. MISTY FAULK WILLIS NURSE PRACTITIONER

Table of content: MRS. MISTY FAULK WILLIS NURSE PRACTITIONER (NPI 1053645697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053645697 NPI number — MRS. MISTY FAULK WILLIS NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
MISTY
Provider Middle Name:
FAULK
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053645697
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
609 E LAMAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMERICUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31709-3737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-924-8636
Provider Business Mailing Address Fax Number:
229-924-8786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 E LAMAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMERICUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31709-3737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-924-8636
Provider Business Practice Location Address Fax Number:
229-924-8786
Provider Enumeration Date:
09/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN177038 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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