MEDICARE: MRS. JOANNE LEE MIRACLE ANP-C; GNP-C

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	363LG0600X	Gerontology Nurse Practitioner	200050105NP	OR
2	363LA2200X	Adult Health Nurse Practitioner	200050105NP	OR

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	:	1922043462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOANNE LEE MIRACLE ANP-C; GNP-C

Provider Business Mailing Address
First Line	:	4560 SE INTERNATIONAL WAY STE 100
Second Line	:
City	:	MILWAUKIE
State	:	OR
Zip	:	97222-4628
Country	:	US
Telephone Number	:	971-206-5179
Fax Number	:	503-905-0495

Provider Business Practice Location Address
First Line	:	4560 SE INTERNATIONAL WAY STE 100
Second Line	:
City	:	MILWAUKIE
State	:	OR
Zip	:	97222-4628
Country	:	US
Telephone Number	:	971-206-5179
Fax Number	:	503-905-0495

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

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	08/10/2020

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