Provider Demographics
NPI:1346350980
Name:TIBBITT, MISTY W (CRNA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:W
Last Name:TIBBITT
Suffix:
Gender:F
Credentials:CRNA
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 4380
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30023-4380
Mailing Address - Country:US
Mailing Address - Phone:706-741-1361
Mailing Address - Fax:
Practice Address - Street 1:5106 GA HIGHWAY 41 S
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:GA
Practice Address - Zip Code:31803-8801
Practice Address - Country:US
Practice Address - Phone:706-741-1361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA154668367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA248844783GMedicaid