Provider Demographics
NPI:1164130753
Name:MCDONNELL, MIRANDA ELISE (AUD, CCC-A, FAAA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELISE
Last Name:MCDONNELL
Suffix:
Gender:F
Credentials:AUD, CCC-A, FAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4719 QUAIL LAKES DR # G209
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8140
Mailing Address - Country:US
Mailing Address - Phone:209-642-3882
Mailing Address - Fax:
Practice Address - Street 1:1095 LOS PALOS DR
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3916
Practice Address - Country:US
Practice Address - Phone:831-422-8798
Practice Address - Fax:831-422-0153
Is Sole Proprietor?:No
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3764231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist