Provider Demographics
NPI:1831817683
Name:MASSEY, MISTY LAVERNE
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:LAVERNE
Last Name:MASSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 PERKINSON RD
Mailing Address - Street 2:
Mailing Address - City:RUFFIN
Mailing Address - State:NC
Mailing Address - Zip Code:27326-9005
Mailing Address - Country:US
Mailing Address - Phone:336-552-3472
Mailing Address - Fax:
Practice Address - Street 1:1100 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6713
Practice Address - Country:US
Practice Address - Phone:336-641-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC74046164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC74046OtherNC BOARD OF NURSING