Provider Demographics
NPI:1518763689
Name:NGANTAR, MISPA KELLYPRIDE BIH
Entity type:Individual
Prefix:
First Name:MISPA KELLYPRIDE
Middle Name:BIH
Last Name:NGANTAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 N 153RD CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-8134
Mailing Address - Country:US
Mailing Address - Phone:402-218-0808
Mailing Address - Fax:
Practice Address - Street 1:2919 N 153RD CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-8134
Practice Address - Country:US
Practice Address - Phone:402-218-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE115849363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily