MEDICARE: MIRANDA LYNN WADDELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	171M00000X	Case Manager/Care Coordinator		OK

General Provider Information

NPI Number	:	1770094047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA LYNN WADDELL

Provider Business Mailing Address
First Line	:	1412 MONUMENT RD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-3620
Country	:	US
Telephone Number	:	405-334-8353
Fax Number	:

Provider Business Practice Location Address
First Line	:	1412 MONUMENT RD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-3620
Country	:	US
Telephone Number	:	405-334-8353
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2017
Last Update Date	:	10/13/2017

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