Healthcare Provider Details

I. General information

NPI: 1023514643
Provider Name (Legal Business Name): MISTY BURTON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 SOUTHCREST CIR
SOUTHAVEN MS
38671-6730
US

IV. Provider business mailing address

391 SOUTHCREST CIR STE 108
SOUTHAVEN MS
38671-4775
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-2659
  • Fax:
Mailing address:
  • Phone: 662-349-2659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24805
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902859
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: