Basic Information
| Provider Information | |||||||||
| NPI: | 1972079853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HESTON | ||||||||
| FirstName: | MISTI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, FNPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FISHER | ||||||||
| OtherFirstName: | MISTI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2100 W IOWA AVE STE A | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052242100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2100 W IOWA AVE STE A | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052242100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2018 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 75310 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 75310 | 01 | OK | OKLAHOMA BOARD OF NURSING | OTHER |