Provider Demographics
NPI:1770243552
Name:GLIDEWELL, MISTY LEIGH (FNP-C)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LEIGH
Last Name:GLIDEWELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MS
Mailing Address - Zip Code:38827-0020
Mailing Address - Country:US
Mailing Address - Phone:662-454-1170
Mailing Address - Fax:662-454-1062
Practice Address - Street 1:8 FRONT ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MS
Practice Address - Zip Code:38827-7764
Practice Address - Country:US
Practice Address - Phone:662-454-1170
Practice Address - Fax:662-454-1062
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905047363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily