Provider Demographics
NPI:1477020071
Name:WASHINGTON, MYRA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:WASHINGTON
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 1:187 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-2455
Mailing Address - Country:US
Mailing Address - Phone:413-531-6796
Mailing Address - Fax:
Practice Address - Street 1:187 COUNTRY CLUB LN
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-2455
Practice Address - Country:US
Practice Address - Phone:413-531-6796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY758288163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse