Provider Demographics
NPI:1225548993
Name:SHOUREK, MIRANNDA LEA
Entity Type:Individual
Prefix:
First Name:MIRANNDA
Middle Name:LEA
Last Name:SHOUREK
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 1:3225 E RANDOLPH AVE APT 5A
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-4603
Mailing Address - Country:US
Mailing Address - Phone:580-231-8121
Mailing Address - Fax:
Practice Address - Street 1:3225 E RANDOLPH
Practice Address - Street 2:APT 5A
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701
Practice Address - Country:US
Practice Address - Phone:580-231-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty