Provider Demographics
NPI:1174222061
Name:MERRIMAN, MYAH ELIZABETH
Entity type:Individual
Prefix:
First Name:MYAH
Middle Name:ELIZABETH
Last Name:MERRIMAN
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 1:153 1/2 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-3702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:153 1/2 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3702
Practice Address - Country:US
Practice Address - Phone:708-345-8960
Practice Address - Fax:708-345-8965
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical