MEDICARE: MISTY AVILA FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1096240	TX

General Provider Information

NPI Number	:	1295450641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY AVILA FNP

Provider Business Mailing Address
First Line	:	2141 BRYN MAWR DR
Second Line	:
City	:	PROSPER
State	:	TX
Zip	:	75078-2434
Country	:	US
Telephone Number	:	512-791-4779
Fax Number	:

Provider Business Practice Location Address
First Line	:	16750 WESTGROVE DR
Second Line	:
City	:	ADDISON
State	:	TX
Zip	:	75001-5688
Country	:	US
Telephone Number	:	214-954-4114
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2022
Last Update Date	:	03/08/2026

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