Provider Demographics
NPI:1982277810
Name:MYRIE, SHATARA (CNA)
Entity type:Individual
Prefix:
First Name:SHATARA
Middle Name:
Last Name:MYRIE
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 POWHATAN AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-1831
Mailing Address - Country:US
Mailing Address - Phone:216-375-0935
Mailing Address - Fax:
Practice Address - Street 1:2620 MEADOWSWEET DR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2627
Practice Address - Country:US
Practice Address - Phone:216-375-0935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH402015151017376K00000X
MIMIOH0056720R376K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No376K00000XNursing Service Related ProvidersNurse's Aide