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General NPI Number Information
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NPI Number | 1700158565
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Entity Type | Individual
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Provider Name | MRS. MARANDA JANE ST. JOHN
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Gender | Female
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Dates
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Enumeration Date | 02/08/2012
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Last Update Date | 02/25/2013
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Provider Practice Location Address
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Address Line | 127 OLD MONTICELLO ST
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City | SOMERSET
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State | KY
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Zip | 42501-2357
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Country | US
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Telephone | 606-271-7878
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Fax | 606-678-2723
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Provider Business Mailing Address
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Address Line | 127 OLD MONTICELLO ST
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City | SOMERSET
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State | KY
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Zip | 42501-2357
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Country | US
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Telephone | 606-271-7878
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Fax | 606-678-2723
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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 | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number | 201132385
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License Number State | KY
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