Provider Demographics
NPI:1619365681
Name:HERMES, MIRANDA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MARIE
Last Name:HERMES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 SAN LUIS PLACE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5211
Mailing Address - Country:US
Mailing Address - Phone:920-494-2817
Mailing Address - Fax:920-494-2855
Practice Address - Street 1:2305 SAN LUIS PLACE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5211
Practice Address - Country:US
Practice Address - Phone:920-494-2817
Practice Address - Fax:920-494-2855
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2213-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant