Basic Information
Provider Information | |||||||||
NPI: | 1861929168 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAHAB | ||||||||
FirstName: | MISTY | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STEPHENS | ||||||||
OtherFirstName: | MISTY | ||||||||
OtherMiddleName: | D. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3755 | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681030755 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023542100 | ||||||||
FaxNumber: | 4023546171 | ||||||||
Practice Location | |||||||||
Address1: | 933 E PIERCE ST | ||||||||
Address2: |   | ||||||||
City: | COUNCIL BLUFFS | ||||||||
State: | IA | ||||||||
PostalCode: | 515034626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7123964360 | ||||||||
FaxNumber: | 7123967069 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2017 | ||||||||
LastUpdateDate: | 04/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A107947 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1861929168 | 05 | IA |   | MEDICAID | 10026327300 | 05 | NE |   | MEDICAID |