Healthcare Provider Details

I. General information

NPI: 1821481334
Provider Name (Legal Business Name): MISTI BALLEW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2015
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 CHANDLER RD
MUSKOGEE OK
74403-4910
US

IV. Provider business mailing address

PO BOX 751
HULBERT OK
74441-0751
US

V. Phone/Fax

Practice location:
  • Phone: 918-478-6005
  • Fax: 918-682-8321
Mailing address:
  • Phone: 918-772-3390
  • Fax: 918-772-2244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number91434
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: