Provider Demographics
NPI:1992531818
Name:ANDERSON, MYRA S
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 GREENWOOD SPRINGS DR APT 1208
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-6067
Mailing Address - Country:US
Mailing Address - Phone:765-823-0896
Mailing Address - Fax:
Practice Address - Street 1:764 GREENWOOD SPRINGS DR APT 1208
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-6067
Practice Address - Country:US
Practice Address - Phone:765-823-0896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2025-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27078540A164W00000X
INHHA0201258374U00000X
INCNA0029787376K00000X
IN28294798C163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide