Provider Demographics
NPI:1518575968
Name:VAN DE LOO, MIRANDA L (DNP, FNP-BC, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:L
Last Name:VAN DE LOO
Suffix:
Gender:F
Credentials:DNP, FNP-BC, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N HOWARD ST STE R
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0508
Mailing Address - Country:US
Mailing Address - Phone:360-836-4314
Mailing Address - Fax:
Practice Address - Street 1:100 N HOWARD ST STE R
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-0508
Practice Address - Country:US
Practice Address - Phone:360-836-4314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI233947363LF0000X
WA2022000625363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily