Provider Demographics
NPI:1831583715
Name:BREAUX, MISTY (RN)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:BREAUX
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 ELK DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625
Mailing Address - Country:US
Mailing Address - Phone:985-518-9432
Mailing Address - Fax:
Practice Address - Street 1:HWY 160/163 BUILDING KA 2010
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033
Practice Address - Country:US
Practice Address - Phone:928-697-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR045218163W00000X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ060012Medicaid
AZHSZ045Medicare PIN
AZ030073Medicare Oscar/Certification