Provider Demographics
NPI:1861929168
Name:WAHAB, MISTY D (ARNP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:D
Last Name:WAHAB
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:D
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:933 E PIERCE ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4626
Practice Address - Country:US
Practice Address - Phone:712-396-4360
Practice Address - Fax:712-396-7069
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA107947363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1861929168Medicaid
NE10026327300Medicaid