=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487102984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISTY DAWN SPROUSE PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2016
-----------------------------------------------------
Last Update Date | 09/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 VALLEY CENTER DRIVE
-----------------------------------------------------
City | STAUNTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-332-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2425 DAVIS RD
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-256-3442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 0024173936
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------