Provider Demographics
NPI:1437439221
Name:KIDD, MYSTII ELLEN (PNP)
Entity Type:Individual
Prefix:
First Name:MYSTII
Middle Name:ELLEN
Last Name:KIDD
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:MYSTII
Other - Middle Name:ELLEN
Other - Last Name:NEKUZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6483
Mailing Address - Fax:682-885-3113
Practice Address - Street 1:4001 W 15TH ST STE 350
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5863
Practice Address - Country:US
Practice Address - Phone:972-596-2131
Practice Address - Fax:682-303-2031
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP107293363LP2300X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1437439221OtherNPI