Provider Demographics
NPI:1194504035
Name:HEAD, MISTY (CNM, WHNP-BC)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:HEAD
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48210-1134
Mailing Address - Country:US
Mailing Address - Phone:313-897-7700
Mailing Address - Fax:
Practice Address - Street 1:6550 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-1134
Practice Address - Country:US
Practice Address - Phone:313-897-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704369275363LW0102X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health