Provider Demographics
NPI:1306370838
Name:MIRANDA, CORRIN (FNP)
Entity Type:Individual
Prefix:
First Name:CORRIN
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CORRIN
Other - Middle Name:
Other - Last Name:WISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3880 SALEM LAKE DR # F
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5292
Mailing Address - Country:US
Mailing Address - Phone:847-719-2220
Mailing Address - Fax:847-719-2265
Practice Address - Street 1:3880 SALEM LAKE DR # F
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047
Practice Address - Country:US
Practice Address - Phone:847-719-2220
Practice Address - Fax:847-719-2265
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015832363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209015832Medicaid
ILMM4319770OtherDEA