Provider Demographics
NPI:1295196137
Name:TOMPKINS, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:TOMPKINS
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:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-864-1472
Mailing Address - Fax:270-858-4607
Practice Address - Street 1:169 MIDDLE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:KY
Practice Address - Zip Code:42602-7931
Practice Address - Country:US
Practice Address - Phone:844-435-0900
Practice Address - Fax:606-858-4607
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-18
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010187363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100403030Medicaid
KY3010187OtherLICENSE NUMBER