Provider Demographics
NPI:1639613946
Name:MIRANDA, ANDREA (PT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PAOLA
Other - Middle Name:A
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1885 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3033
Mailing Address - Country:US
Mailing Address - Phone:904-277-4449
Mailing Address - Fax:
Practice Address - Street 1:1885 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3033
Practice Address - Country:US
Practice Address - Phone:904-277-4449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist