Healthcare Provider Details

I. General information

NPI: 1114146727
Provider Name (Legal Business Name): MARILYN JOE MYERS LPN LICENSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6338 BRUSH LAKE RD
NORTH LEWISBURG OH
43060-9621
US

IV. Provider business mailing address

6338 BRUSH LAKE RD
NORTH LEWISBURG OH
43060-9621
US

V. Phone/Fax

Practice location:
  • Phone: 937-747-3706
  • Fax:
Mailing address:
  • Phone: 937-747-3706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374T00000X
TaxonomyReligious Nonmedical Nursing Personnel
License NumberPN.117346
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: