Provider Demographics
NPI:1083789788
Name:SUDDETH, MISTY MESHELL (FNP-L)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:MESHELL
Last Name:SUDDETH
Suffix:
Gender:F
Credentials:FNP-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 EAST MORRIS STREET
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721
Mailing Address - Country:US
Mailing Address - Phone:706-272-1645
Mailing Address - Fax:706-272-1648
Practice Address - Street 1:508 EAST MORRIS STREET
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721
Practice Address - Country:US
Practice Address - Phone:706-272-1645
Practice Address - Fax:706-272-1648
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113269 NP363L00000X
TNAPN000007995367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife