Provider Demographics
NPI:1003378100
Name:MYRICK, ANGELA NICOLE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:MYRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-2703
Mailing Address - Country:US
Mailing Address - Phone:440-752-9806
Mailing Address - Fax:
Practice Address - Street 1:1117 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-2703
Practice Address - Country:US
Practice Address - Phone:440-752-9806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH001030175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH175T00000XMedicaid