Provider Demographics
NPI:1699389361
Name:GREEN, MISTYANNE
Entity Type:Individual
Prefix:
First Name:MISTYANNE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:232 COOPER DR
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-6129
Mailing Address - Country:US
Mailing Address - Phone:972-567-0718
Mailing Address - Fax:
Practice Address - Street 1:1606 N SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-2733
Practice Address - Country:US
Practice Address - Phone:972-567-0718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT133835225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist