Provider Demographics
NPI:1639398506
Name:PACE, MYRNA RUTH
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:RUTH
Last Name:PACE
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 1:1849 E DANA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-1319
Mailing Address - Country:US
Mailing Address - Phone:480-835-5015
Mailing Address - Fax:
Practice Address - Street 1:1849 E DANA AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-1319
Practice Address - Country:US
Practice Address - Phone:480-835-5015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5181171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor