Healthcare Provider Details

I. General information

NPI: 1487438495
Provider Name (Legal Business Name): MIRANDA M THURMOND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 190TH ST STE 280
GARDENA CA
90248-4305
US

IV. Provider business mailing address

3522 FONTAINE AVE
JACKSON MS
39213-5657
US

V. Phone/Fax

Practice location:
  • Phone: 877-515-8113
  • Fax:
Mailing address:
  • Phone: 601-564-3012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number906212
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: