Healthcare Provider Details

I. General information

NPI: 1891052494
Provider Name (Legal Business Name): MISTY LINN ANDERSON HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 LEON SULLIVAN WAY
CHARLESTON WV
25301-2409
US

IV. Provider business mailing address

215 SHUMAN BLVD SUITE 401
NAPERVILLE IL
60563-8458
US

V. Phone/Fax

Practice location:
  • Phone: 304-346-6521
  • Fax: 304-346-6512
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number807
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: