Provider Demographics
NPI:1811975881
Name:ROBERTSON, MISTY WHITE (CRNP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:WHITE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 S JACKSON HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660-5773
Mailing Address - Country:US
Mailing Address - Phone:256-383-4447
Mailing Address - Fax:256-381-7999
Practice Address - Street 1:351 HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:KILLEN
Practice Address - State:AL
Practice Address - Zip Code:35645
Practice Address - Country:US
Practice Address - Phone:256-272-8066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1083613363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P73378Medicare UPIN