=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952917502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRANDA EDDY TALMAGE CPNP-PC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2020
-----------------------------------------------------
Last Update Date | 09/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1508 COGSWELL AVE
-----------------------------------------------------
City | PELL CITY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35125-1243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-418-4300
-----------------------------------------------------
Fax | 888-827-8932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 BIRCHALL LN APT 306
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35226-6444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-317-7175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 1-144300
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------