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General NPI Number Information
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NPI Number | 1194485532
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Entity Type | Individual
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Provider Name | MIRANDA RENEE WILSON FNP
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Gender | Female
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Dates
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Enumeration Date | 12/27/2021
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Last Update Date | 12/27/2021
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Provider Practice Location Address
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Address Line | 354 W FOOTHILL BLVD
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City | CLAREMONT
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State | CA
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Zip | 91711-2709
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Country | US
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Telephone | 909-624-1215
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Fax |
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Provider Business Mailing Address
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Address Line | 14051 ROBIN CREST LN
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City | CHINO HILLS
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State | CA
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Zip | 91709-4822
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Country | US
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Telephone | 951-751-5233
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 95019330
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License Number State | CA
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