Provider Demographics
NPI:1508069899
Name:TINGLE, MIRANDA LYNETTE (LOTR)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:LYNETTE
Last Name:TINGLE
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 ROSALIE DR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2732
Mailing Address - Country:US
Mailing Address - Phone:318-245-0719
Mailing Address - Fax:
Practice Address - Street 1:903 ROSALIE DR
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2732
Practice Address - Country:US
Practice Address - Phone:318-245-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ11184225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist