Provider Demographics
NPI:1598411647
Name:WIRTZ, MIRANDA LYNN (RN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LYNN
Last Name:WIRTZ
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 1:410 S ADEWAY STE C
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:IN
Mailing Address - Zip Code:47944-8418
Mailing Address - Country:US
Mailing Address - Phone:765-884-1343
Mailing Address - Fax:765-884-2026
Practice Address - Street 1:410 S ADEWAY STE C
Practice Address - Street 2:
Practice Address - City:FOWLER
Practice Address - State:IN
Practice Address - Zip Code:47944-8418
Practice Address - Country:US
Practice Address - Phone:765-884-1343
Practice Address - Fax:765-884-2026
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28238968A163WC1500X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health