Healthcare Provider Details

I. General information

NPI: 1508410317
Provider Name (Legal Business Name): MIRANDA MCKINNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9521 SAN MATEO BLVD NE
ALBUQUERQUE NM
87113-2237
US

IV. Provider business mailing address

6401 AVENIDA MADRID NW
ALBUQUERQUE NM
87114-1454
US

V. Phone/Fax

Practice location:
  • Phone: 505-923-5703
  • Fax:
Mailing address:
  • Phone: 702-335-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: