Provider Demographics
NPI:1649256967
Name:MISSEY, JANIS LEE (PT)
Entity type:Individual
Prefix:
First Name:JANIS
Middle Name:LEE
Last Name:MISSEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JANIS
Other - Middle Name:LEE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:3195 STILLWATER DR
Mailing Address - Street 2:STE A
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7171
Mailing Address - Country:US
Mailing Address - Phone:928-771-9327
Mailing Address - Fax:928-771-9519
Practice Address - Street 1:3195 STILLWATER DR
Practice Address - Street 2:STE A
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7171
Practice Address - Country:US
Practice Address - Phone:928-777-9327
Practice Address - Fax:928-771-9519
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ781410Medicaid
AZ781410Medicaid
AZ76278Medicare ID - Type Unspecified