Healthcare Provider Details

I. General information

NPI: 1982105938
Provider Name (Legal Business Name): MARANDA SHAYANNICE PAGE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8951 CYPRESS WATERS BLVD STE 160
COPPELL TX
75019-4282
US

IV. Provider business mailing address

215 E CORLEY LN
SPARTANBURG SC
29303-2625
US

V. Phone/Fax

Practice location:
  • Phone: 612-217-4967
  • Fax:
Mailing address:
  • Phone: 864-410-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21586
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: