MEDICARE: MIRANDA WIKERT

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	163W00000X	Registered Nurse	1631127	CA

General Provider Information

NPI Number	:	1346794468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA WIKERT

Provider Business Mailing Address
First Line	:	2036 SADDLEBACK DR
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-9493
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2036 SADDLEBACK DR
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-9493
Country	:	US
Telephone Number	:	909-936-4861
Fax Number	:

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

Provider Enumeration Date	:	08/05/2016
Last Update Date	:	08/05/2016

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Directions to “ MIRANDA WIKERT ” Practice Location

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