Provider Demographics
NPI:1003443417
Name:RYCRAW, MYRTLE
Entity Type:Individual
Prefix:
First Name:MYRTLE
Middle Name:
Last Name:RYCRAW
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 1:4800 SOUTHWICK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2235
Mailing Address - Country:US
Mailing Address - Phone:708-747-2655
Mailing Address - Fax:
Practice Address - Street 1:4800 SOUTHWICK DR STE 300
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2235
Practice Address - Country:US
Practice Address - Phone:708-747-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker