Provider Demographics
NPI:1164429791
Name:MYRICK, KAREN M (APRN)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:M
Last Name:MYRICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:M
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:65 KANE ST
Mailing Address - Street 2:PROVIDER ENROLLMENT, 2ND FLOOR
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2110
Mailing Address - Country:US
Mailing Address - Phone:860-523-6421
Mailing Address - Fax:860-523-3701
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:UCONN MEDICAL GROUP, ORTHOPAEDICS
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-6600
Practice Address - Fax:860-679-6604
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT02247363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4220480Medicaid
CT500000784Medicare PIN
CT4220480Medicaid