Provider Demographics
NPI:1518296656
Name:LANDOR, MISTY (NP-C)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:LANDOR
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CHORLEY RUN
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2927
Mailing Address - Country:US
Mailing Address - Phone:404-683-9844
Mailing Address - Fax:
Practice Address - Street 1:109 CONSTITUTION DR STE 500
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8047
Practice Address - Country:US
Practice Address - Phone:478-419-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN173390363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health