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General NPI Number Information
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NPI Number | 1528823705
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Entity Type | Individual
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Provider Name | MRS. MIRANDA MARTIN MCMAHAN
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Gender | Female
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Dates
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Enumeration Date | 02/16/2024
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Last Update Date | 02/16/2024
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Provider Practice Location Address
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Address Line | 330 SW ADAMS ST
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City | PEORIA
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State | IL
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Zip | 61602-1502
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Country | US
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Telephone | 309-402-2978
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Fax |
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Provider Business Mailing Address
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Address Line | 3421 E CEDAR POINT DR
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City | CHILLICOTHEE
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State | IL
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Zip | 61523-9238
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Country | US
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Telephone | 309-402-2978
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209.029312
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License Number State | IL
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