Healthcare Provider Details

I. General information

NPI: 1871407536
Provider Name (Legal Business Name): MYLENA HARRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2590 ONSLOW DR
JACKSONVILLE NC
28540-5600
US

IV. Provider business mailing address

10 DOCTORS CIR STE 6
SUPPLY NC
28462-4218
US

V. Phone/Fax

Practice location:
  • Phone: 252-773-0195
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP024699
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: