Provider Demographics
NPI:1780103796
Name:HENSON, MISTY
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:HENSON
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 1:476490 E 1060 RD
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-5159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:476490 E 1060 RD
Practice Address - Street 2:
Practice Address - City:MULDROW
Practice Address - State:OK
Practice Address - Zip Code:74948-5159
Practice Address - Country:US
Practice Address - Phone:918-427-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician