Provider Demographics
NPI:1578804654
Name:SANBORN, MIRANDA (CRNP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:SANBORN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:CARLACCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:32 CLEARWATER CT
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-2334
Mailing Address - Country:US
Mailing Address - Phone:301-253-1862
Mailing Address - Fax:
Practice Address - Street 1:32 CLEARWATER CT
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872-2334
Practice Address - Country:US
Practice Address - Phone:301-253-1862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR150998363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner