Healthcare Provider Details

I. General information

NPI: 1639538424
Provider Name (Legal Business Name): MISTY DAWN MORA CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 ANTHONY DR.
ANTHONY NM
88021-4530
US

IV. Provider business mailing address

P.O. BOX 4530
ANTHONY TX
79821-4530
US

V. Phone/Fax

Practice location:
  • Phone: 575-882-2956
  • Fax: 575-882-1863
Mailing address:
  • Phone: 575-882-2956
  • Fax: 575-882-1863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP129834
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCNP-02836
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: