Provider Demographics
NPI:1558812701
Name:TROUT, MIRANDA (RN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:TROUT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-2008
Mailing Address - Country:US
Mailing Address - Phone:417-235-6610
Mailing Address - Fax:417-476-1082
Practice Address - Street 1:411 3RD ST
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-2008
Practice Address - Country:US
Practice Address - Phone:417-235-6610
Practice Address - Fax:417-476-1082
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012007919163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse