Provider Demographics
NPI:1639151657
Name:MENJOULET, MYRA LYN (WHNP)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:LYN
Last Name:MENJOULET
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 W LIBERTY ST
Mailing Address - Street 2:SUITE 3002
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1921
Mailing Address - Country:US
Mailing Address - Phone:573-756-9107
Mailing Address - Fax:573-756-9630
Practice Address - Street 1:1105 W LIBERTY ST
Practice Address - Street 2:SUITE 3002
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1921
Practice Address - Country:US
Practice Address - Phone:573-756-9107
Practice Address - Fax:573-756-9630
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO077826363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S08435Medicare UPIN