Provider Demographics
NPI:1801160718
Name:MCBRIDE, MISTY DAWN (CPM)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2244 BARTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3408
Mailing Address - Country:US
Mailing Address - Phone:865-206-1075
Mailing Address - Fax:530-578-0016
Practice Address - Street 1:5301 LONGLEY LN STE A8
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-1805
Practice Address - Country:US
Practice Address - Phone:865-206-1075
Practice Address - Fax:530-600-1015
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM433176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife