Provider Demographics
NPI:1992407878
Name:TATUM, MISTY
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:TATUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:HIGGINBOTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:853 JEFFERSON AVENUE
Mailing Address - Street 2:ROUT 2ND FLOOR
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:853 JEFFERSON AVENUE
Practice Address - Street 2:ROUT 2ND FLOOR
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2804
Practice Address - Country:US
Practice Address - Phone:901-866-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN163029363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care