Provider Demographics
NPI:1740580935
Name:MONTELLANO, MISTY D (NP-C)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:D
Last Name:MONTELLANO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-1152
Mailing Address - Country:US
Mailing Address - Phone:940-766-6306
Mailing Address - Fax:940-766-6404
Practice Address - Street 1:200 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-1152
Practice Address - Country:US
Practice Address - Phone:940-766-6306
Practice Address - Fax:940-766-6504
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661454363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner