Provider Demographics
NPI:1629372313
Name:BROOKS, MISTY DAWN (CRNA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:BROOKS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8636 NAOMI ST
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7811
Mailing Address - Country:US
Mailing Address - Phone:903-277-9665
Mailing Address - Fax:
Practice Address - Street 1:12222 N CENTRAL EXPY
Practice Address - Street 2:SUITE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3755
Practice Address - Country:US
Practice Address - Phone:214-219-3747
Practice Address - Fax:214-219-3748
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX687861367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280599601Medicaid