Provider Demographics
NPI:1760695639
Name:VANDERGRIFF, MIRANDA DANIELLE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:DANIELLE
Last Name:VANDERGRIFF
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:MIRANDA
Other - Middle Name:DANIELLE
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:2905 CRESCENT CIR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37407-1323
Mailing Address - Country:US
Mailing Address - Phone:423-304-7491
Mailing Address - Fax:
Practice Address - Street 1:921 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2102
Practice Address - Country:US
Practice Address - Phone:423-209-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000056631164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse