Healthcare Provider Details

I. General information

NPI: 1093502270
Provider Name (Legal Business Name): KELLIANN RUTH MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 BENSON DR STE AND102
RALEIGH NC
27609-7321
US

IV. Provider business mailing address

15 TUSCAN CT
YOUNGSVILLE NC
27596-8029
US

V. Phone/Fax

Practice location:
  • Phone: 984-325-6889
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP021896
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: