Provider Demographics
NPI:1477178739
Name:TELLINGHUISEN, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:TELLINGHUISEN
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 1:1977 N RUBY CT
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2178
Mailing Address - Country:US
Mailing Address - Phone:612-554-1366
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-554-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist