Provider Demographics
NPI:1417619131
Name:MIRANDA, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:MIRANDA
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 1:4350 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-6026
Mailing Address - Country:US
Mailing Address - Phone:510-712-8561
Mailing Address - Fax:
Practice Address - Street 1:1919 CUTTING BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-2662
Practice Address - Country:US
Practice Address - Phone:510-233-8513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00250026374U00000X
CA00826074376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide