Provider Demographics
NPI:1316247448
Name:KERSEY, MYRA SUSAN (RN)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:SUSAN
Last Name:KERSEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-2708
Mailing Address - Country:US
Mailing Address - Phone:870-633-1795
Mailing Address - Fax:870-261-1818
Practice Address - Street 1:836 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2708
Practice Address - Country:US
Practice Address - Phone:870-633-1795
Practice Address - Fax:870-261-1818
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR65618164W00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR124245761Medicaid