MEDICARE: WILSON MIRANDA

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	407245	NY

General Provider Information

NPI Number	:	1578448635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILSON MIRANDA

Provider Business Mailing Address
First Line	:	1535 GREENE AVE APT 2L
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11237-6912
Country	:	US
Telephone Number	:	917-676-2347
Fax Number	:

Provider Business Practice Location Address
First Line	:	1535 GREENE AVE APT 2L
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11237-6912
Country	:	US
Telephone Number	:	917-676-2347
Fax Number	:

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

Provider Enumeration Date	:	08/07/2025
Last Update Date	:	08/07/2025

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Directions to “ WILSON MIRANDA ” Practice Location

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