Healthcare Provider Details

I. General information

NPI: 1972428761
Provider Name (Legal Business Name): GENESSIS MICHELLE PORRAS MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37114 AGATE CT
PALMDALE CA
93550-7321
US

IV. Provider business mailing address

37114 AGATE CT
PALMDALE CA
93550-7321
US

V. Phone/Fax

Practice location:
  • Phone: 661-503-0363
  • Fax:
Mailing address:
  • Phone: 661-503-0363
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: