Provider Demographics
NPI:1780343988
Name:WEATHINGTON, MISTY
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:WEATHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:WETZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7598 LAKE PARK RD
Mailing Address - Street 2:
Mailing Address - City:IRA
Mailing Address - State:MI
Mailing Address - Zip Code:48023-2519
Mailing Address - Country:US
Mailing Address - Phone:586-746-7754
Mailing Address - Fax:
Practice Address - Street 1:400 STODDARD RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-2505
Practice Address - Country:US
Practice Address - Phone:810-392-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist