MEDICARE: MRS. MIRANDA JO DAVID R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1500X	Community Health Registered Nurse	128371	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144390329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MIRANDA JO DAVID R.N.

Provider Business Mailing Address
First Line	:	PO BOX 482
Second Line	:
City	:	DIVIDE
State	:	CO
Zip	:	80814-0482
Country	:	US
Telephone Number	:	719-687-6494
Fax Number	:

Provider Business Practice Location Address
First Line	:	11505 W. HWY. 24
Second Line	:
City	:	DIVIDE
State	:	CO
Zip	:	80814
Country	:	US
Telephone Number	:	719-687-6416
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/09/2007

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