Healthcare Provider Details

I. General information

NPI: 1902945975
Provider Name (Legal Business Name): NICOLE ANDRE MIRANDA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 E. ORCHARD RD. SUITE 110
CENTENNIAL CO
80112
US

IV. Provider business mailing address

7120 E. ORCHARD RD. SUITE 110
CENTENNIAL CO
80112
US

V. Phone/Fax

Practice location:
  • Phone: 303-850-7717
  • Fax: 303-850-7517
Mailing address:
  • Phone: 303-850-7717
  • Fax: 303-850-7517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7905
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: