Provider Demographics
NPI:1700430733
Name:MYRICK, NAOMI
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:MYRICK
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 1:3600 W BROAD ST UNIT 536
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-4948
Mailing Address - Country:US
Mailing Address - Phone:757-653-4131
Mailing Address - Fax:
Practice Address - Street 1:601 N MECHANIC ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1455
Practice Address - Country:US
Practice Address - Phone:757-653-4131
Practice Address - Fax:619-374-4204
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177963363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1700430733Medicaid