MEDICARE: MISTY NIROCA PAUL

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	164W00000X	Licensed Practical Nurse	63334	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00503772	OTHER	TN	DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1942710520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY NIROCA PAUL

Provider Business Mailing Address
First Line	:	800 PARKS ST
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-2482
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2702 ROBERTS RIDGE RD
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-4246
Country	:	US
Telephone Number	:	931-312-0369
Fax Number	:

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

Provider Enumeration Date	:	10/09/2017
Last Update Date	:	10/09/2017

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Directions to “ MISTY NIROCA PAUL ” Practice Location

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