Provider Demographics
NPI:1205178407
Name:MIRACLE, ANGELA LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYNN
Last Name:MIRACLE
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 1:54818 US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:OH
Mailing Address - Zip Code:45647-8938
Mailing Address - Country:US
Mailing Address - Phone:740-637-0754
Mailing Address - Fax:
Practice Address - Street 1:54818 US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:OH
Practice Address - Zip Code:45647-8938
Practice Address - Country:US
Practice Address - Phone:740-637-0754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.147291-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse