Provider Demographics
NPI:1497465744
Name:COLEGROVE, MIRANDA ELISE (MS)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELISE
Last Name:COLEGROVE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1468 BRIARWOOD RD NE UNIT 1402
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-5742
Mailing Address - Country:US
Mailing Address - Phone:979-583-8896
Mailing Address - Fax:
Practice Address - Street 1:3001 MERCER UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4115
Practice Address - Country:US
Practice Address - Phone:678-547-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program