Provider Demographics
NPI:1700510302
Name:STEVENSON, MISTY (RN)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11497 HIGHWAY 49 STE B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3152
Mailing Address - Country:US
Mailing Address - Phone:228-332-7695
Mailing Address - Fax:228-678-7146
Practice Address - Street 1:11497 HIGHWAY 49 STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3152
Practice Address - Country:US
Practice Address - Phone:228-323-7695
Practice Address - Fax:228-678-7146
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR885868163WC0400X, 163WH1000X, 163WW0000X, 163WH0200X
MS16753253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No253Z00000XAgenciesIn Home Supportive Care