MEDICARE: MRS. MIRANDA LEE GOFORTH FNP

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	R874514	AR
2	363LF0000X	Family Nurse Practitioner	15025	TN
3	363LF0000X	Family Nurse Practitioner	218923	AR

General Provider Information

NPI Number	:	1891015467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MIRANDA LEE GOFORTH FNP

Provider Business Mailing Address
First Line	:	146 PASSION PLAY RD STE A
Second Line	:
City	:	EUREKA SPRINGS
State	:	AR
Zip	:	72632-9455
Country	:	US
Telephone Number	:	479-253-9746
Fax Number	:

Provider Business Practice Location Address
First Line	:	146 PASSION PLAY RD STE A
Second Line	:
City	:	EUREKA SPRINGS
State	:	AR
Zip	:	72632-9455
Country	:	US
Telephone Number	:	479-253-9746
Fax Number	:

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

Provider Enumeration Date	:	06/07/2010
Last Update Date	:	06/17/2022

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