Provider Demographics
NPI:1154959591
Name:LEDESMA, MISTY RAE (NP-C)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:RAE
Last Name:LEDESMA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60207 65TH ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49057-8711
Mailing Address - Country:US
Mailing Address - Phone:269-674-9909
Mailing Address - Fax:
Practice Address - Street 1:32652 KNO
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-9805
Practice Address - Country:US
Practice Address - Phone:269-782-4141
Practice Address - Fax:269-783-1236
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704244777363L00000X
MI4204244777363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner