Provider Demographics
NPI:1164297206
Name:MIRANDA CRUZ, JAINESS (RD)
Entity Type:Individual
Prefix:
First Name:JAINESS
Middle Name:
Last Name:MIRANDA CRUZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 UPHAM ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3335
Mailing Address - Country:US
Mailing Address - Phone:787-241-2563
Mailing Address - Fax:
Practice Address - Street 1:85 HERRICK ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1777
Practice Address - Country:US
Practice Address - Phone:787-241-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALDN7108133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered