Provider Demographics
NPI:1245766146
Name:COLE, MIRANDA ELISE
Entity Type:Individual
Prefix:MISS
First Name:MIRANDA
Middle Name:ELISE
Last Name:COLE
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 1:1717 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1324
Mailing Address - Country:US
Mailing Address - Phone:940-799-7922
Mailing Address - Fax:
Practice Address - Street 1:1717 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1324
Practice Address - Country:US
Practice Address - Phone:940-799-7922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other