Provider Demographics
NPI:1083321376
Name:FUGATE, MIRANDA (LPN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:FUGATE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7246 CREEKVIEW DR APT 9
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-3025
Mailing Address - Country:US
Mailing Address - Phone:513-335-8121
Mailing Address - Fax:
Practice Address - Street 1:830 EZZARD CHARLES DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45214-2525
Practice Address - Country:US
Practice Address - Phone:513-381-6672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH163278164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty