Provider Demographics
NPI:1518460021
Name:KAMDJIO MIYO, MIRABELLE CLAUDINE
Entity Type:Individual
Prefix:DR
First Name:MIRABELLE
Middle Name:CLAUDINE
Last Name:KAMDJIO MIYO
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 1:9700 COPPER LAKE CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-4711
Mailing Address - Country:US
Mailing Address - Phone:916-509-9994
Mailing Address - Fax:
Practice Address - Street 1:9700 COPPER LAKE CT
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-4711
Practice Address - Country:US
Practice Address - Phone:916-509-9994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-10
Last Update Date:2018-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist