=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154703577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRANDA ALLEN D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2015
-----------------------------------------------------
Last Update Date | 06/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1009 44TH ST SW STE 101
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49509-4480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-828-4622
-----------------------------------------------------
Fax | 616-635-2552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 BODIN CIR
-----------------------------------------------------
City | TRAVIS AFB
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94535-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-423-5224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 5101021905
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------