Provider Demographics
NPI:1588237812
Name:MERRILL, MIRANDA (ATC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MERRILL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:FAUCETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:382 NORTH MCKELVY AVENUE
Mailing Address - Street 2:#239
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611
Mailing Address - Country:US
Mailing Address - Phone:425-293-4904
Mailing Address - Fax:
Practice Address - Street 1:1620 E BULLDOG LANE M/S OF 87
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93740-0001
Practice Address - Country:US
Practice Address - Phone:559-278-2643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer