Provider Demographics
NPI:1487382719
Name:STEVENS, MISTY MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:MARIE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 S 600 E
Mailing Address - Street 2:
Mailing Address - City:GAS CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46933-9547
Mailing Address - Country:US
Mailing Address - Phone:765-618-7785
Mailing Address - Fax:
Practice Address - Street 1:6326 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1518
Practice Address - Country:US
Practice Address - Phone:260-515-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-14
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012917A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care