Healthcare Provider Details

I. General information

NPI: 1811648918
Provider Name (Legal Business Name): MYA NICHELLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W BALTIMORE AVE APT H
LANSDOWNE PA
19050-2139
US

IV. Provider business mailing address

1626 LOCUST ST
PHILADELPHIA PA
19103-6305
US

V. Phone/Fax

Practice location:
  • Phone: 610-809-8332
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TAMIYA WADE
Title or Position: OWNER
Credential:
Phone: 610-809-8332