Provider Demographics
NPI:1457553729
Name:MYERS, EILEEN S (RD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:S
Last Name:MYERS
Suffix:
Gender:F
Credentials:RD
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 16345
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32035-3123
Mailing Address - Country:US
Mailing Address - Phone:615-330-6669
Mailing Address - Fax:
Practice Address - Street 1:2594 FOREST RIDGE DR APT M-4
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-0407
Practice Address - Country:US
Practice Address - Phone:615-330-6669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN001722133V00000X
FLND9141133V00000X
TN1722133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty