Provider Demographics
NPI:1689381592
Name:ANZALDI, MIRANDA JEAN
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JEAN
Last Name:ANZALDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11940 SE HAROLD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3916
Mailing Address - Country:US
Mailing Address - Phone:503-916-9473
Mailing Address - Fax:
Practice Address - Street 1:627 SE 13TH AVE APT A
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4863
Practice Address - Country:US
Practice Address - Phone:503-916-9473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant