Provider Demographics
NPI:1427369206
Name:WITHERS, MIRANDA D (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:D
Last Name:WITHERS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 BOGLE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2895
Mailing Address - Country:US
Mailing Address - Phone:606-679-0179
Mailing Address - Fax:606-679-0546
Practice Address - Street 1:349 BOGLE ST STE A
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2895
Practice Address - Country:US
Practice Address - Phone:606-679-0179
Practice Address - Fax:606-679-0546
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6526P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100130590Medicaid
KY7100130590Medicaid