Healthcare Provider Details

I. General information

NPI: 1801160718
Provider Name (Legal Business Name): MISTY DAWN MCBRIDE CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 LONGLEY LN STE A8
RENO NV
89511-1805
US

IV. Provider business mailing address

2244 BARTON AVE
SOUTH LAKE TAHOE CA
96150-3408
US

V. Phone/Fax

Practice location:
  • Phone: 865-206-1075
  • Fax: 530-600-1015
Mailing address:
  • Phone: 865-206-1075
  • Fax: 530-578-0016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: