Healthcare Provider Details

I. General information

NPI: 1871092155
Provider Name (Legal Business Name): MIRANDA CHRISTINE OGDEN RN, MSN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRANDA CHRISTINE JARMAN

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 CHANNING WAY
IDAHO FALLS ID
83404-7517
US

IV. Provider business mailing address

1067 W 125 S
BLACKFOOT ID
83221-6058
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-7667
  • Fax:
Mailing address:
  • Phone: 208-317-6285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number57772
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: