Healthcare Provider Details

I. General information

NPI: 1114409125
Provider Name (Legal Business Name): MIIA MCCANTS CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/10/2022
Certification Date: 09/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 IGNICO DR APT 103-4
WARNER ROBINS GA
31093-8670
US

IV. Provider business mailing address

135 IGNICO DR APT 103-4
WARNER ROBINS GA
31093-8670
US

V. Phone/Fax

Practice location:
  • Phone: 973-752-7845
  • Fax:
Mailing address:
  • Phone: 973-752-7845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number26NP07354300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: