Provider Demographics
NPI:1659097244
Name:LONG, MISTY (MSN, APRN, CNM)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MSN, APRN, CNM
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2008 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-4554
Mailing Address - Country:US
Mailing Address - Phone:432-557-9918
Mailing Address - Fax:
Practice Address - Street 1:2008 E 56TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-4554
Practice Address - Country:US
Practice Address - Phone:432-557-9918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-14
Last Update Date:2022-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1096837367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife