1568400042 NPI number — JOAN MYRICK LMP

Table of content: JOAN MYRICK LMP (NPI 1568400042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568400042 NPI number — JOAN MYRICK LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYRICK
Provider First Name:
JOAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568400042
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1519 132ND ST SE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98208-7203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-330-0633
Provider Business Mailing Address Fax Number:
425-338-9637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7728 204TH ST NE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98223-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-403-8250
Provider Business Practice Location Address Fax Number:
360-403-0917
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7679705 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8854MY . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8875MY . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0146797 . This is a "DEPT. OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8928862 . This is a "L&I CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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