Provider Demographics
NPI:1134687114
Name:SHINE, MISTI DAWN (NP-BC)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:DAWN
Last Name:SHINE
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8591 HOLLY MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:WV
Mailing Address - Zip Code:26287-8604
Mailing Address - Country:US
Mailing Address - Phone:304-478-3339
Mailing Address - Fax:
Practice Address - Street 1:8591 HOLLY MEADOWS RD
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:WV
Practice Address - Zip Code:26287-8604
Practice Address - Country:US
Practice Address - Phone:304-478-3339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN57107-NP-C363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily