Provider Demographics
NPI:1376328732
Name:PEROTTI, MIRANDA ELYSE (RN IBCLC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELYSE
Last Name:PEROTTI
Suffix:
Gender:F
Credentials:RN IBCLC
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:ELYSE
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3007 WOODLAND HILLS DR # 205
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-1403
Mailing Address - Country:US
Mailing Address - Phone:281-305-0411
Mailing Address - Fax:281-572-0627
Practice Address - Street 1:2101 WEST AVE UNIT 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-2822
Practice Address - Country:US
Practice Address - Phone:281-305-0411
Practice Address - Fax:281-572-0627
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX878063163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant