Healthcare Provider Details

I. General information

NPI: 1730937947
Provider Name (Legal Business Name): GABRIELLE MIRANDA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2024
Last Update Date: 05/11/2024
Certification Date: 05/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

882 CLAY FIELD TRL
SUMMERVILLE SC
29485-9249
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-3100
  • Fax:
Mailing address:
  • Phone: 803-640-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number349509
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: