MEDICARE: MISTY LANDOR NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	RN173390	GA

General Provider Information

NPI Number	:	1518296656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY LANDOR NP-C

Provider Business Mailing Address
First Line	:	121 CHORLEY RUN
Second Line	:
City	:	ELLENWOOD
State	:	GA
Zip	:	30294-2927
Country	:	US
Telephone Number	:	404-683-9844
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 CONSTITUTION DR STE 500
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-8047
Country	:	US
Telephone Number	:	478-419-0411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2009
Last Update Date	:	04/02/2024

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