Healthcare Provider Details

I. General information

NPI: 1275395733
Provider Name (Legal Business Name): MIRANDA HALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1891 FORT RD 11
SHERIDAN WY
82801
US

IV. Provider business mailing address

345 W 3RD ST
PARKER SD
57053-2269
US

V. Phone/Fax

Practice location:
  • Phone: 307-672-3473
  • Fax:
Mailing address:
  • Phone: 605-351-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberR054984
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: