Provider Demographics
NPI:1417977380
Name:EMMETT, MYRA ELAINE
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:ELAINE
Last Name:EMMETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:ELAINE
Other - Last Name:SHAMLOO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5150 BAYOU BLVD
Mailing Address - Street 2:SUITE 1N
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2158
Mailing Address - Country:US
Mailing Address - Phone:850-416-6790
Mailing Address - Fax:850-416-7348
Practice Address - Street 1:2441 N 9TH AVE STE B
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-3989
Practice Address - Country:US
Practice Address - Phone:850-741-9004
Practice Address - Fax:850-416-7348
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL758230700Medicaid