Healthcare Provider Details

I. General information

NPI: 1891510186
Provider Name (Legal Business Name): MIRANDA TAPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 SUMMIT AVE
SOUTH SAINT PAUL MN
55075-1226
US

IV. Provider business mailing address

1108 SUMMIT AVE
SOUTH SAINT PAUL MN
55075-1226
US

V. Phone/Fax

Practice location:
  • Phone: 651-795-8275
  • Fax:
Mailing address:
  • Phone: 651-795-8275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number2491629
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: