Basic Information
| Provider Information | |||||||||
| NPI: | 1568653525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | MISSY | ||||||||
| MiddleName: | LANETT | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10765 KENWORTHY ST STE A | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799241748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153204021 | ||||||||
| FaxNumber: | 9153204031 | ||||||||
| Practice Location | |||||||||
| Address1: | 10765 KENWORTHY ST STE A | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799241748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153204021 | ||||||||
| FaxNumber: | 9153204031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 606521 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | NP-990035 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | CNP-02441 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 31129374 | 05 | CO | MEDICAID |