Healthcare Provider Details

I. General information

NPI: 1629995022
Provider Name (Legal Business Name): MIRANDA MICHELLE DONAHUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4803 CASPIAN WAVE DR
LEAGUE CITY TX
77573-6303
US

IV. Provider business mailing address

4803 CASPIAN WAVE DR
LEAGUE CITY TX
77573-6303
US

V. Phone/Fax

Practice location:
  • Phone: 956-328-1015
  • Fax:
Mailing address:
  • Phone: 956-328-1015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License Number859398
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: