Provider Demographics
NPI:1659903144
Name:FARIS, MIRANDA LOUISE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LOUISE
Last Name:FARIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11188 N 550 E
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-8947
Mailing Address - Country:US
Mailing Address - Phone:219-964-5312
Mailing Address - Fax:
Practice Address - Street 1:11188 N 550 E
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-8947
Practice Address - Country:US
Practice Address - Phone:219-964-5312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF07191270363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily