Provider Demographics
NPI:1447609383
Name:WISENBAKER, MIRANDA PAIGE (CPNP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:PAIGE
Last Name:WISENBAKER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:PAIGE
Other - Last Name:CAHEELY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2918 E WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-8724
Mailing Address - Country:US
Mailing Address - Phone:706-529-4633
Mailing Address - Fax:
Practice Address - Street 1:2918 E WALNUT AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8724
Practice Address - Country:US
Practice Address - Phone:706-529-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN223590363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner