Healthcare Provider Details

I. General information

NPI: 1114928439
Provider Name (Legal Business Name): MISTY HALLONQUIST BLALOCK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY H MORRISSEY NP

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 LINDA DR
DAINGERFIELD TX
75638-2130
US

IV. Provider business mailing address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 430-226-5110
  • Fax: 430-226-5111
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number651612
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: