Healthcare Provider Details

I. General information

NPI: 1144390329
Provider Name (Legal Business Name): MIRANDA JO DAVID R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11505 W. HWY. 24
DIVIDE CO
80814
US

IV. Provider business mailing address

PO BOX 482
DIVIDE CO
80814-0482
US

V. Phone/Fax

Practice location:
  • Phone: 719-687-6416
  • Fax:
Mailing address:
  • Phone: 719-687-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number128371
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: