Provider Demographics
NPI:1659735256
Name:MIRANDA, JODI (CLE)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:CLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33133-6615
Mailing Address - Country:US
Mailing Address - Phone:407-375-1672
Mailing Address - Fax:
Practice Address - Street 1:9275 SW 152ND ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1701
Practice Address - Country:US
Practice Address - Phone:305-498-6722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-09
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4-201604174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator