Healthcare Provider Details

I. General information

NPI: 1437906104
Provider Name (Legal Business Name): MIRANDA NICOLE OGLE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7491
US

IV. Provider business mailing address

2207 W KING ST
KOKOMO IN
46901-5024
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6684
  • Fax:
Mailing address:
  • Phone: 765-271-0107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: