Provider Demographics
NPI:1639607625
Name:BLAIS, MIRANDA FORDHAM (WHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:FORDHAM
Last Name:BLAIS
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 PARK VALLEY DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-6251
Mailing Address - Country:US
Mailing Address - Phone:706-248-6020
Mailing Address - Fax:
Practice Address - Street 1:3369 BUFORD HWY NE STE 810A
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-1742
Practice Address - Country:US
Practice Address - Phone:404-321-4692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216488207V00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology