Healthcare Provider Details

I. General information

NPI: 1124458963
Provider Name (Legal Business Name): MIRATUS LOUIS MOLINE ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5258 LINTON BLVD # G1
DELRAY BEACH FL
33484-6540
US

IV. Provider business mailing address

6326 HARBOUR OAK DR
LAKE WORTH FL
33467-6840
US

V. Phone/Fax

Practice location:
  • Phone: 561-330-4695
  • Fax: 561-330-4696
Mailing address:
  • Phone: 239-641-2050
  • Fax: 561-330-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9251699
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: