MEDICARE: MISS MYRA HYACINTH CLARKE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN276508	OH
2	163WH0200X	Home Health Registered Nurse	RN276508	OH

General Provider Information

NPI Number	:	1336424662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MYRA HYACINTH CLARKE RN

Provider Business Mailing Address
First Line	:	3418 MEADOWBROOK BLVD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-3431
Country	:	US
Telephone Number	:	216-799-2279
Fax Number	:

Provider Business Practice Location Address
First Line	:	3418 MEADOWBROOK BLVD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-3431
Country	:	US
Telephone Number	:	216-799-2279
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2011
Last Update Date	:	04/17/2015

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