Provider Demographics
NPI:1093481277
Name:DRAKE, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4373 STATE ROUTE 19 S
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:14813-9513
Mailing Address - Country:US
Mailing Address - Phone:585-610-8560
Mailing Address - Fax:
Practice Address - Street 1:45 MAPLE ST
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-9182
Practice Address - Country:US
Practice Address - Phone:585-335-5052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341985-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16-1039939Medicaid
NY16-1039939OtherALL OTHER INSURANCES