Provider Demographics
NPI:1417206541
Name:HARTMIRE, MISTY R (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:R
Last Name:HARTMIRE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:R
Other - Last Name:POOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:452 OLD CORYDON RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-4645
Mailing Address - Country:US
Mailing Address - Phone:270-826-0200
Mailing Address - Fax:270-826-0212
Practice Address - Street 1:101 NW 1ST ST STE 215
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47708-1259
Practice Address - Country:US
Practice Address - Phone:124-375-1928
Practice Address - Fax:270-826-0212
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007632363LF0000X
IN71009038A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100230100Medicaid
IN300029096Medicaid