Provider Demographics
NPI:1578363511
Name:HARRIS, MYA NICHOLLE
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:NICHOLLE
Last Name:HARRIS
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 1:4210 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68111-3427
Mailing Address - Country:US
Mailing Address - Phone:402-904-0946
Mailing Address - Fax:
Practice Address - Street 1:4210 LAKE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68111-3427
Practice Address - Country:US
Practice Address - Phone:402-904-0946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant