Healthcare Provider Details

I. General information

NPI: 1124658844
Provider Name (Legal Business Name): MIRANDA LENN-MORAN CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 N CIRCLE DR STE 100
COLORADO SPRINGS CO
80909-1174
US

IV. Provider business mailing address

4317 HESSITE LOOP
COLORADO SPRINGS CO
80938-9602
US

V. Phone/Fax

Practice location:
  • Phone: 720-590-9629
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA.0002598
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: