Healthcare Provider Details

I. General information

NPI: 1386451615
Provider Name (Legal Business Name): MIRANDA CARSON O'LEARY NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRANDA ALEXIS CARSON

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

2008 KELSEY BAY CT
CHESAPEAKE VA
23323-5346
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-0000
  • Fax:
Mailing address:
  • Phone: 757-325-7822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number24192047
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: