1982069316 NPI number — VIRGINIA MARIE MISSILDINE FNP

Table of content: VIRGINIA MARIE MISSILDINE FNP (NPI 1982069316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982069316 NPI number — VIRGINIA MARIE MISSILDINE FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISSILDINE
Provider First Name:
VIRGINIA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1982069316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2709
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-792-5924
Provider Business Mailing Address Fax Number:
903-792-8224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1102 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-792-5924
Provider Business Practice Location Address Fax Number:
903-792-8224
Provider Enumeration Date:
12/30/2015

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:  AP129782 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: A005417 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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