Healthcare Provider Details

I. General information

NPI: 1245876242
Provider Name (Legal Business Name): MIRANDA MARSHALL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 JEFFERSON WAY STE 101
KETCHIKAN AK
99901-5953
US

IV. Provider business mailing address

PO BOX 1099
WARD COVE AK
99928-1099
US

V. Phone/Fax

Practice location:
  • Phone: 907-247-9999
  • Fax:
Mailing address:
  • Phone: 907-247-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number183598
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: