Provider Demographics
NPI:1093544603
Name:MYALO MENTAL HEALTH, PLLC
Entity type:Organization
Organization Name:MYALO MENTAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:602-647-8249
Mailing Address - Street 1:21639 N 12TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-2802
Mailing Address - Country:US
Mailing Address - Phone:602-647-8249
Mailing Address - Fax:
Practice Address - Street 1:21639 N 12TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-2802
Practice Address - Country:US
Practice Address - Phone:602-647-8249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-31
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP4920OtherCERTIFIED NURSE PRACTITIONER LICENSE
AZ822748Medicaid