Provider Demographics
NPI:1487157772
Name:MOON-HARRIS, MISTI JAYNE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:MISTI
Middle Name:JAYNE
Last Name:MOON-HARRIS
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 1:2948 NW 33RD ST
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73065-6580
Mailing Address - Country:US
Mailing Address - Phone:405-410-3905
Mailing Address - Fax:
Practice Address - Street 1:8125 S WALKER AVE STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9417
Practice Address - Country:US
Practice Address - Phone:405-619-4479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK73220363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner