Healthcare Provider Details

I. General information

NPI: 1780686865
Provider Name (Legal Business Name): MITZI DANIELA MUSICK ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 05/05/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W STONE DR STE 3A
KINGSPORT TN
37660-3365
US

IV. Provider business mailing address

PO BOX 9 ATTN: CREDENTIALING
NASHVILLE TN
37201-1835
US

V. Phone/Fax

Practice location:
  • Phone: 423-392-6200
  • Fax: 423-390-4411
Mailing address:
  • Phone: 865-978-6182
  • Fax: 855-737-5542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN0000116388
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0001162148
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000007650
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024165213
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: