Healthcare Provider Details

I. General information

NPI: 1174778468
Provider Name (Legal Business Name): EMILY MYATT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W UNIVERSITY AVE
MUNCIE IN
47303-3428
US

IV. Provider business mailing address

6805 BAYVIEW CLUB DR APT 2C
INDIANAPOLIS IN
46250-2472
US

V. Phone/Fax

Practice location:
  • Phone: 765-747-3273
  • Fax:
Mailing address:
  • Phone: 812-340-0176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: