Healthcare Provider Details

I. General information

NPI: 1760658744
Provider Name (Legal Business Name): MARANDA LEE VINCENT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST STE 2C
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

1235 E CHEROKEE ST STE 2C
SPRINGFIELD MO
65804-2203
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-3911
  • Fax:
Mailing address:
  • Phone: 417-820-3911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2001004401
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: