Provider Demographics
NPI:1770040222
Name:ANDERSON, MIRICLE (NP)
Entity Type:Individual
Prefix:
First Name:MIRICLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CASSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65625-1610
Mailing Address - Country:US
Mailing Address - Phone:417-847-5225
Mailing Address - Fax:
Practice Address - Street 1:92 MAIN ST
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-1610
Practice Address - Country:US
Practice Address - Phone:417-847-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019005210363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily