Healthcare Provider Details

I. General information

NPI: 1477272094
Provider Name (Legal Business Name): MIRANDA ODEGARD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10561 E CAMINO CIR
MESA AZ
85207-3145
US

IV. Provider business mailing address

10561 E CAMINO CIR
MESA AZ
85207-3145
US

V. Phone/Fax

Practice location:
  • Phone: 480-758-0716
  • Fax:
Mailing address:
  • Phone: 480-758-0716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number236747
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: