Provider Demographics
NPI:1093246027
Name:MYRICK, RADIAH
Entity Type:Individual
Prefix:
First Name:RADIAH
Middle Name:
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 1:200 78TH AVE N APT 73
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 78TH AVE N APT 73
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4466
Practice Address - Country:US
Practice Address - Phone:727-712-7661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL120806172V00000X, 405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No172V00000XOther Service ProvidersCommunity Health Worker