Provider Demographics
NPI:1659800050
Name:NICHOLSON, MISTY-LYNN (CPT)
Entity Type:Individual
Prefix:
First Name:MISTY-LYNN
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 WHISPERING PINE BLVD
Mailing Address - Street 2:
Mailing Address - City:MELISSA
Mailing Address - State:TX
Mailing Address - Zip Code:75454-2653
Mailing Address - Country:US
Mailing Address - Phone:585-749-0077
Mailing Address - Fax:
Practice Address - Street 1:3011 WHISPERING PINE BLVD
Practice Address - Street 2:
Practice Address - City:MELISSA
Practice Address - State:TX
Practice Address - Zip Code:75454
Practice Address - Country:US
Practice Address - Phone:585-749-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCPTE161215-1713472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCPTE161215-171347OtherCPT