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General NPI Number Information
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NPI Number | 1518703933
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Entity Type | Individual
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Provider Name | MIRANDA A BLACK LPN
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Gender | Female
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Dates
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Enumeration Date | 07/04/2024
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Last Update Date | 05/19/2025
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Provider Practice Location Address
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Address Line | 2230 PHOENIX AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32206-3159
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Country | US
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Telephone | 904-466-7339
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Fax |
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Provider Business Mailing Address
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Address Line | 1985 W 30TH ST
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City | JACKSONVILLE
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State | FL
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Zip | 32209-3787
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Country | US
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Telephone | 904-466-7339
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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 | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | PN5169477
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 9674808
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License Number State | FL
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