Healthcare Provider Details

I. General information

NPI: 1447836044
Provider Name (Legal Business Name): GUINNEVERE MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6109 CARR 694
VEGA ALTA PR
00692-9781
US

IV. Provider business mailing address

HC 5 BOX 9706
COROZAL PR
00783-9656
US

V. Phone/Fax

Practice location:
  • Phone: 787-270-0460
  • Fax: 787-270-0475
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number8197
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: