Healthcare Provider Details

I. General information

NPI: 1023599404
Provider Name (Legal Business Name): RONALD JAMES MIRENDA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 N BROAD ST
WINDER GA
30680
US

IV. Provider business mailing address

4681 GLEN LEVEL DR
SUGAR HILL GA
30518-6299
US

V. Phone/Fax

Practice location:
  • Phone: 770-867-2120
  • Fax: 770-867-2140
Mailing address:
  • Phone: 706-580-7163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN220139
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: