Healthcare Provider Details

I. General information

NPI: 1528419884
Provider Name (Legal Business Name): MIRANDA KNAPP MSN, RN, AGCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 SUCCESSFUL DR
FAIRBORN OH
45324-9239
US

IV. Provider business mailing address

4969 SHANNON AVE
SPRINGFIELD OH
45504-3381
US

V. Phone/Fax

Practice location:
  • Phone: 937-231-6105
  • Fax:
Mailing address:
  • Phone: 937-231-6105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number396960
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: