Provider Demographics
NPI:1558859397
Name:MIRACLE, LEIDY DESIRED
Entity Type:Individual
Prefix:
First Name:LEIDY
Middle Name:DESIRED
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEIDY
Other - Middle Name:DESIRED
Other - Last Name:PEREZ-MAZARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5225 WHITE COYOTE PL
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-1627
Mailing Address - Country:US
Mailing Address - Phone:702-575-3718
Mailing Address - Fax:
Practice Address - Street 1:5225 WHITE COYOTE PL
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-1627
Practice Address - Country:US
Practice Address - Phone:702-575-3718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program