MEDICARE: MS. MYRA LYN MENJOULET WHNP

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	363LW0102X	Women's Health Nurse Practitioner	077826	MO

General Provider Information

NPI Number	:	1639151657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MYRA LYN MENJOULET WHNP

Provider Business Mailing Address
First Line	:	1105 W LIBERTY ST
Second Line	:	SUITE 3002
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1921
Country	:	US
Telephone Number	:	573-756-9107
Fax Number	:	573-756-9630

Provider Business Practice Location Address
First Line	:	1105 W LIBERTY ST
Second Line	:	SUITE 3002
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1921
Country	:	US
Telephone Number	:	573-756-9107
Fax Number	:	573-756-9630

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

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	07/08/2007

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