Healthcare Provider Details

I. General information

NPI: 1104193325
Provider Name (Legal Business Name): MIRANDA BISANGHA GWANYALLA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 PARK PLACE BLVD
KISSIMMEE FL
34741-2344
US

IV. Provider business mailing address

206 PARK PLACE BLVD
KISSIMMEE FL
34741-2344
US

V. Phone/Fax

Practice location:
  • Phone: 407-846-0023
  • Fax: 407-483-1064
Mailing address:
  • Phone: 407-846-0023
  • Fax: 407-483-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9308438
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: