Provider Demographics
NPI:1568653525
Name:RICHARDSON, MISSY LANETT (NP)
Entity Type:Individual
Prefix:
First Name:MISSY
Middle Name:LANETT
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10765 KENWORTHY ST STE A
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-1748
Mailing Address - Country:US
Mailing Address - Phone:915-320-4021
Mailing Address - Fax:915-320-4031
Practice Address - Street 1:10765 KENWORTHY ST STE A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-1748
Practice Address - Country:US
Practice Address - Phone:915-320-4021
Practice Address - Fax:915-320-4031
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX606521363L00000X
CONP-990035363LF0000X
NMCNP-02441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31129374Medicaid
COCOA109656Medicare PIN
NM365321YMBVMedicare PIN
COCOAAA3655Medicare PIN