Provider Demographics
NPI:1821509241
Name:FITZPATRICK, MIRANDA (FNP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:807 CHEROKEE DR STE 5
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-1690
Mailing Address - Country:US
Mailing Address - Phone:660-202-4227
Mailing Address - Fax:
Practice Address - Street 1:807 CHEROKEE DR STE 5
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-1690
Practice Address - Country:US
Practice Address - Phone:660-202-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN245226163W00000X, 363LF0000X
MO2024006900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily