Provider Demographics
NPI:1144509159
Name:MYRICK, NIKEL S
Entity type:Individual
Prefix:
First Name:NIKEL
Middle Name:S
Last Name:MYRICK
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 1:250 ROSEVILLE AVE.
Mailing Address - Street 2:APT 5
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107
Mailing Address - Country:US
Mailing Address - Phone:973-395-6908
Mailing Address - Fax:
Practice Address - Street 1:784 CLINTON AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108-1045
Practice Address - Country:US
Practice Address - Phone:973-395-6908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities