Provider Demographics
NPI:1356823454
Name:MERRILL, MYRACLE
Entity Type:Individual
Prefix:
First Name:MYRACLE
Middle Name:
Last Name:MERRILL
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 1:8675 GAVEL DR
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-1948
Mailing Address - Country:US
Mailing Address - Phone:210-618-5956
Mailing Address - Fax:
Practice Address - Street 1:6655 FIRST PARK TEN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-4304
Practice Address - Country:US
Practice Address - Phone:210-733-3246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX336186164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse