Provider Demographics
NPI:1376047308
Name:POLLARD, MIRANDA NICOLE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NICOLE
Last Name:POLLARD
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 1:2514 MAYAPPLE RD E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-4268
Mailing Address - Country:US
Mailing Address - Phone:904-616-8146
Mailing Address - Fax:
Practice Address - Street 1:2514 MAYAPPLE RD E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-4268
Practice Address - Country:US
Practice Address - Phone:904-616-8146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities