Healthcare Provider Details

I. General information

NPI: 1033325600
Provider Name (Legal Business Name): MISTY BLUE YOUNGBEAR LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 HWY 446
NIXON NV
89424
US

IV. Provider business mailing address

420 GREGORY STREET PO BOX 757
WADSWORTH NV
89442
US

V. Phone/Fax

Practice location:
  • Phone: 775-574-1018
  • Fax: 775-574-1028
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN14094
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number822707
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: