1336005883 NPI number — MYSTI BLU NURSING, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336005883 NPI number — MYSTI BLU NURSING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYSTI BLU NURSING, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1336005883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2459 E HEBRON PKWY STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75010-4477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2459 EAST HEBRON PKWY
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-522-9799
Provider Business Practice Location Address Fax Number:
469-546-9723
Provider Enumeration Date:
12/29/2025

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BERNESTINE
Authorized Official First Name:
JERRIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-522-9799

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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