Healthcare Provider Details

I. General information

NPI: 1518382522
Provider Name (Legal Business Name): MISTY MOSS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3406 COLLEGE ST
BEAUMONT TX
77701-4612
US

IV. Provider business mailing address

3406 COLLEGE ST
BEAUMONT TX
77701-4612
US

V. Phone/Fax

Practice location:
  • Phone: 409-813-2332
  • Fax: 409-813-2710
Mailing address:
  • Phone: 409-813-2332
  • Fax: 409-813-2710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number675149
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: