Provider Demographics
NPI:1235888074
Name:MENEZES, MYRNA (LPN)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:MENEZES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BAYBERRY LN
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-5101
Mailing Address - Country:US
Mailing Address - Phone:133-978-8104
Mailing Address - Fax:
Practice Address - Street 1:3 BAYBERRY LN
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-5101
Practice Address - Country:US
Practice Address - Phone:339-788-1049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN88760164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS98090805OtherDRIVER'S LICENSE