Provider Demographics
NPI:1467639039
Name:SIKORA, MYRA JANE (RD, LD)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:JANE
Last Name:SIKORA
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8601 CROWS NEST RD
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-9098
Mailing Address - Country:US
Mailing Address - Phone:228-826-5011
Mailing Address - Fax:
Practice Address - Street 1:8601 CROWS NEST RD
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-9098
Practice Address - Country:US
Practice Address - Phone:228-826-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1261133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered