Provider Demographics
NPI:1003384603
Name:DEHAVEN, MISTY LYNN (APN)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LYNN
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 957
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61105-0957
Mailing Address - Country:US
Mailing Address - Phone:815-395-1500
Mailing Address - Fax:815-395-1415
Practice Address - Street 1:1639 N ALPINE RD STE 260
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1481
Practice Address - Country:US
Practice Address - Phone:815-395-1500
Practice Address - Fax:815-395-1415
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018358363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL359727415OtherSOCIAL SECURITY