Healthcare Provider Details

I. General information

NPI: 1194480541
Provider Name (Legal Business Name): MIRANDA ALEXANDER BAZEMORE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6380 PROMENADE PKWY
CASTLE ROCK CO
80108-1909
US

IV. Provider business mailing address

6380 PROMENADE PKWY
CASTLE ROCK CO
80108-1909
US

V. Phone/Fax

Practice location:
  • Phone: 720-734-1126
  • Fax:
Mailing address:
  • Phone: 720-734-1126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberC-APN.0106561
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberGAA-NP000506
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: