Provider Demographics
NPI:1952743973
Name:KING, MISTY DAWN (RN)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:KING
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:DAWN
Other - Last Name:BOZARTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:
Practice Address - Street 1:2920 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-5924
Practice Address - Country:US
Practice Address - Phone:618-731-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041305914163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse