Provider Demographics
NPI:1134832074
Name:TATOM, MISTY DAWN (ARNP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:TATOM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 W LEAGUE CITY PKWY
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-7339
Mailing Address - Country:US
Mailing Address - Phone:713-737-5219
Mailing Address - Fax:
Practice Address - Street 1:1507 W LEAGUE CITY PKWY
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-7339
Practice Address - Country:US
Practice Address - Phone:713-737-5219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX894413163W00000X
WAAP61530730363LF0000X
TX1108433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse