Provider Demographics
NPI:1326697442
Name:MOSS, MIRANDA ELIZABETH (APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:ELIZABETH
Last Name:MOSS
Suffix:
Gender:F
Credentials:APRN, FNP-C
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 23321
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-3321
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:1 BURNT CHURCH RD STE A
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6405
Practice Address - Country:US
Practice Address - Phone:843-706-2185
Practice Address - Fax:843-299-5693
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23205363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP6357Medicaid