Provider Demographics
NPI:1437678810
Name:JEWELL, MIRANDA JO (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:JO
Last Name:JEWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:MIRANDA
Other - Middle Name:JO
Other - Last Name:STAPLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6644
Mailing Address - Fax:270-858-4027
Practice Address - Street 1:301 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3487
Practice Address - Country:US
Practice Address - Phone:270-651-9696
Practice Address - Fax:270-651-0385
Is Sole Proprietor?:No
Enumeration Date:2017-09-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011720363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3011720OtherKENTUCKY MEDICAL LICENSE