Provider Demographics
NPI:1376898569
Name:WING, MIRANDA RENEE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:RENEE
Last Name:WING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MIRANDA
Other - Middle Name:RENEE
Other - Last Name:WADDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1 CATAMORE BLVD
Mailing Address - Street 2:
Mailing Address - City:E PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914
Mailing Address - Country:US
Mailing Address - Phone:401-438-0008
Mailing Address - Fax:401-438-2272
Practice Address - Street 1:1 CATAMORE BLVD
Practice Address - Street 2:
Practice Address - City:E PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914
Practice Address - Country:US
Practice Address - Phone:401-438-0008
Practice Address - Fax:401-438-2272
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN01755363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2316320Medicaid
249644YJAMMedicare PIN