Provider Demographics
NPI:1093853046
Name:ALDERMAN, MYRA LYNN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:LYNN
Last Name:ALDERMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:LYNN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 749
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-3658
Mailing Address - Country:US
Mailing Address - Phone:318-728-0175
Mailing Address - Fax:318-728-0173
Practice Address - Street 1:121 CHRISTIAN DR
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-3658
Practice Address - Country:US
Practice Address - Phone:318-728-0175
Practice Address - Fax:318-728-0173
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP02066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1530913Medicaid