Provider Demographics
NPI:1306872387
Name:ALLEN, MISTY C (CRNA)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:C
Last Name:ALLEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490210
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-0210
Mailing Address - Country:US
Mailing Address - Phone:352-326-4014
Mailing Address - Fax:
Practice Address - Street 1:2862 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4631
Practice Address - Country:US
Practice Address - Phone:352-326-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-047642367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG4193OtherBLUE SHIELD
AL51511554OtherBCBS
MS06234720Medicaid
430076327OtherPALMETTO GBA-RR MEDICARE
AL051552673Medicaid
430076327OtherPALMETTO GBA-RR MEDICARE
MS06234720Medicaid
FLG4193OtherBLUE SHIELD