Provider Demographics
NPI:1386899961
Name:AGEN-DAVIS, MYRTIS MARVELL MCCAIN (PMHNP-BC, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MYRTIS
Middle Name:MARVELL MCCAIN
Last Name:AGEN-DAVIS
Suffix:
Gender:
Credentials:PMHNP-BC, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 OLD FREDERICK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-2126
Mailing Address - Country:US
Mailing Address - Phone:410-775-6394
Mailing Address - Fax:410-881-2477
Practice Address - Street 1:5411 OLD FREDERICK RD STE 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-2126
Practice Address - Country:US
Practice Address - Phone:410-775-6394
Practice Address - Fax:410-881-2477
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR157786163WM0705X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily