Healthcare Provider Details

I. General information

NPI: 1588509368
Provider Name (Legal Business Name): MIRANDA SMITH
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 BYHALIA RD
HERNANDO MS
38632-1003
US

IV. Provider business mailing address

1481 BYHALIA RD
HERNANDO MS
38632-1003
US

V. Phone/Fax

Practice location:
  • Phone: 662-469-2906
  • Fax:
Mailing address:
  • Phone: 662-469-2906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8098
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: