Basic Information
| Provider Information | |||||||||
| NPI: | 1821242728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYROM | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19564 S LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563345042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206344033 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10 4TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563341820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206344521 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2008 | ||||||||
| LastUpdateDate: | 11/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R156714-4 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.