Provider Demographics
NPI:1205059003
Name:MYHRE, NICOLE (FP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MYHRE
Suffix:
Gender:F
Credentials:FP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35906 W MERCED STREET
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85239
Mailing Address - Country:US
Mailing Address - Phone:602-696-8609
Mailing Address - Fax:
Practice Address - Street 1:35906 W MERCED STREET
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85239
Practice Address - Country:US
Practice Address - Phone:602-696-8609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ114121Medicare ID - Type Unspecified