Provider Demographics
NPI:1790886703
Name:TALAVERA, MYRNA
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:
Last Name:TALAVERA
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:PO BOX 2362
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662-2004
Mailing Address - Country:US
Mailing Address - Phone:178-787-2515
Mailing Address - Fax:
Practice Address - Street 1:77 CALLE MANUEL CORCHADO JUARBE
Practice Address - Street 2:
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662-2973
Practice Address - Country:US
Practice Address - Phone:787-872-5159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR194156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician