Provider Demographics
NPI:1952806705
Name:FAMILARA, MYRA BLAZO
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:BLAZO
Last Name:FAMILARA
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 1:7345 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1737
Mailing Address - Country:US
Mailing Address - Phone:317-286-2885
Mailing Address - Fax:317-536-3097
Practice Address - Street 1:3050 MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-3619
Practice Address - Country:US
Practice Address - Phone:818-957-0850
Practice Address - Fax:818-249-2386
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95061272163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse