Provider Demographics
NPI:1467847822
Name:MCGILLEM, MISTY AUTUMN (DNP)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:AUTUMN
Last Name:MCGILLEM
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4575 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3509
Mailing Address - Country:US
Mailing Address - Phone:520-325-4268
Mailing Address - Fax:520-318-6935
Practice Address - Street 1:3939 S PARK AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-1635
Practice Address - Country:US
Practice Address - Phone:520-333-4320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9889363LP0808X
AZRN 175929163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ235041Medicaid