Provider Demographics
NPI:1407126535
Name:MYERSON, MICHELLE LYNN
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LYNN
Last Name:MYERSON
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 1:4101 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3524
Mailing Address - Country:US
Mailing Address - Phone:954-966-7473
Mailing Address - Fax:
Practice Address - Street 1:4101 THOMAS ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3524
Practice Address - Country:US
Practice Address - Phone:954-966-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 9329171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor