Provider Demographics
NPI:1578954657
Name:MYKLAK, RINA (NP)
Entity Type:Individual
Prefix:
First Name:RINA
Middle Name:
Last Name:MYKLAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 30TH AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6009
Mailing Address - Country:US
Mailing Address - Phone:877-522-1275
Mailing Address - Fax:509-491-3031
Practice Address - Street 1:3301 30TH AVE S STE 102
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6009
Practice Address - Country:US
Practice Address - Phone:877-522-1275
Practice Address - Fax:833-888-7145
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201500844NP PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201500844NP PPOtherOREGON NURSE PRACTITIONER LICENSE