Provider Demographics
NPI:1265887053
Name:MYRIE, ALICIA (NP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:MYRIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BEAVER DAM RD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9719
Mailing Address - Country:US
Mailing Address - Phone:631-286-8100
Mailing Address - Fax:
Practice Address - Street 1:192 LONGFELLOW DR
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-2224
Practice Address - Country:US
Practice Address - Phone:631-816-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY603197-1163W00000X
NYF308824363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse