Healthcare Provider Details

I. General information

NPI: 1871413047
Provider Name (Legal Business Name): MIRANDA MCELLIGOTT
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 MILWAUKEE ST
MADISON WI
53707-5001
US

IV. Provider business mailing address

3902 MILWAUKEE ST
MADISON WI
53707-5001
US

V. Phone/Fax

Practice location:
  • Phone: 608-571-4906
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1796133
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: