Healthcare Provider Details

I. General information

NPI: 1124969985
Provider Name (Legal Business Name): ADDIE MIRANDA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LEESTOWN RD STE 338
LEXINGTON KY
40511-2047
US

IV. Provider business mailing address

1500 LEESTOWN RD STE 338
LEXINGTON KY
40511-2047
US

V. Phone/Fax

Practice location:
  • Phone: 859-317-8295
  • Fax: 859-317-8410
Mailing address:
  • Phone: 859-317-8295
  • Fax: 859-317-8410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number297411
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: