Provider Demographics
NPI:1962708347
Name:MAYFIELD, MISTY D (FNP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:D
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:FNP
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 2839
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2839
Mailing Address - Country:US
Mailing Address - Phone:601-553-0707
Mailing Address - Fax:601-553-0775
Practice Address - Street 1:2514 67TH AVENUE LOOP
Practice Address - Street 2:SUITE 112
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-7259
Practice Address - Country:US
Practice Address - Phone:601-553-0707
Practice Address - Fax:601-553-0775
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864583363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09076220Medicaid