Provider Demographics
NPI:1629702089
Name:LEE, MIRANDA MUN-LAI (LAT, ATC)
Entity Type:Individual
Prefix:MISS
First Name:MIRANDA
Middle Name:MUN-LAI
Last Name:LEE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 SANDS PARC BLVD APT 307
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-0052
Mailing Address - Country:US
Mailing Address - Phone:860-986-4532
Mailing Address - Fax:
Practice Address - Street 1:1200 W INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2817
Practice Address - Country:US
Practice Address - Phone:386-506-3989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL63462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer