Healthcare Provider Details

I. General information

NPI: 1922889849
Provider Name (Legal Business Name): MIRANDA KAAKE MS, PA (ASCP)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

145 INDIAN CREEK DR
COVINGTON KY
41017-9139
US

V. Phone/Fax

Practice location:
  • Phone: 513-301-2542
  • Fax:
Mailing address:
  • Phone: 812-972-1351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: