Provider Demographics
NPI:1083902654
Name:VELAZQUEZ, MYRNA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:MYRNA
Other - Middle Name:
Other - Last Name:MONTANEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:909 RIDGEBROOK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9477
Mailing Address - Country:US
Mailing Address - Phone:443-383-9300
Mailing Address - Fax:855-866-8710
Practice Address - Street 1:101 POTTERS LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-1017
Practice Address - Country:US
Practice Address - Phone:443-383-9300
Practice Address - Fax:855-866-8710
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily