MEDICARE: MIRANDA WILDER

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	235Z00000X	Speech-Language Pathologist	4543	KS

General Provider Information

NPI Number	:	1306411145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA WILDER

Provider Business Mailing Address
First Line	:	13418 OAKBROOK DR
Second Line	:
City	:	KEARNEY
State	:	MO
Zip	:	64060-8093
Country	:	US
Telephone Number	:	816-797-9690
Fax Number	:

Provider Business Practice Location Address
First Line	:	888 HAINES STE 114
Second Line	:
City	:	LIBERTY
State	:	MO
Zip	:	64068-1008
Country	:	US
Telephone Number	:	816-797-9690
Fax Number	:

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

Provider Enumeration Date	:	05/24/2021
Last Update Date	:	12/09/2024

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Directions to “ MIRANDA WILDER ” Practice Location

Language	Start Address	Practice Location

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