Provider Demographics
NPI:1174005490
Name:DOYLE, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:DOYLE
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 1:126 PINE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9214
Mailing Address - Country:US
Mailing Address - Phone:609-744-9640
Mailing Address - Fax:
Practice Address - Street 1:126 PINE VALLEY DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9214
Practice Address - Country:US
Practice Address - Phone:609-744-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer