Provider Demographics
NPI:1326559584
Name:WHARTON, MISTY DAWN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:DAWN
Last Name:WHARTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 W MARION RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:OH
Mailing Address - Zip Code:43338-1085
Mailing Address - Country:US
Mailing Address - Phone:419-688-6860
Mailing Address - Fax:
Practice Address - Street 1:528 W MARION RD
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:OH
Practice Address - Zip Code:43338-1085
Practice Address - Country:US
Practice Address - Phone:419-947-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131050164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse