Healthcare Provider Details

I. General information

NPI: 1962284646
Provider Name (Legal Business Name): MIRA BETH THIGPEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 10/22/2023
Certification Date: 10/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

3804 OGLETHORPE DR
WINTERVILLE NC
28590-9799
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7000
  • Fax:
Mailing address:
  • Phone: 908-328-4413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberTHIG-S1S08
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: