Provider Demographics
NPI:1821242728
Name:MYROM, JENNA NICOLE (FNP)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:NICOLE
Last Name:MYROM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19564 S LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-5042
Mailing Address - Country:US
Mailing Address - Phone:320-634-4033
Mailing Address - Fax:
Practice Address - Street 1:10 4TH AVE SE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1820
Practice Address - Country:US
Practice Address - Phone:320-634-4521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR156714-4363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily