Healthcare Provider Details

I. General information

NPI: 1861288581
Provider Name (Legal Business Name): MARY MIRANDA CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2025
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 STINE RD
BAKERSFIELD CA
93309-4176
US

IV. Provider business mailing address

12620 MACLURE DR
BAKERSFIELD CA
93311-8671
US

V. Phone/Fax

Practice location:
  • Phone: 661-619-4088
  • Fax:
Mailing address:
  • Phone: 818-359-3598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: