Healthcare Provider Details

I. General information

NPI: 1346269016
Provider Name (Legal Business Name): LAURIE ANN MIRANDA AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 RONALD REAGAN PKWY STE 254
AVON IN
46123-6911
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-6467
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23001906A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: