Healthcare Provider Details

I. General information

NPI: 1740198969
Provider Name (Legal Business Name): MIRANDA ELIZABETH SUDDUTH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRANDA ELIZABETH WIETELMAN RN

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S AVENUE A
YUMA AZ
85364-7127
US

IV. Provider business mailing address

2027 S MAGNOLIA AVE
YUMA AZ
85364-6101
US

V. Phone/Fax

Practice location:
  • Phone: 928-336-2000
  • Fax:
Mailing address:
  • Phone: 928-336-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number337417
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: