Provider Demographics
NPI:1396744710
Name:PARKER, MISTY M (ACNP-BC)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:M
Last Name:PARKER
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 FLOWERING DOGWOOD LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-6409
Mailing Address - Country:US
Mailing Address - Phone:731-287-0804
Mailing Address - Fax:731-285-3600
Practice Address - Street 1:1385 FLOWERING DOGWOOD LN
Practice Address - Street 2:SUITE C
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-6409
Practice Address - Country:US
Practice Address - Phone:731-287-0804
Practice Address - Fax:731-285-3600
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11037363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515855Medicaid
TN36480701Medicare PIN