Provider Demographics
NPI:1598229643
Name:PROFFITT, MARANDA
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:
Last Name:PROFFITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2745 E CECIL AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93292-8036
Mailing Address - Country:US
Mailing Address - Phone:559-900-5507
Mailing Address - Fax:
Practice Address - Street 1:530 KINGS COUNTY DR STE 106
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5954
Practice Address - Country:US
Practice Address - Phone:559-676-8116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAMPSS-KFHEIS175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator