Provider Demographics
NPI:1508884917
Name:MYROM, SHELLY JOAN (CNP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:JOAN
Last Name:MYROM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:JOAN
Other - Last Name:MYROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-6319
Mailing Address - Country:US
Mailing Address - Phone:507-333-3300
Mailing Address - Fax:507-333-3214
Practice Address - Street 1:300 STATE AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:507-333-3300
Practice Address - Fax:507-333-3214
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0848026363L00000X
MN1378363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN093820300Medicaid
S58510Medicare UPIN