Provider Demographics
NPI:1821514316
Name:SMITH, MIRANDA JANE (NP-C)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:JANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5458 COLONY TRACE CT
Mailing Address - Street 2:
Mailing Address - City:SATSUMA
Mailing Address - State:AL
Mailing Address - Zip Code:36572-2409
Mailing Address - Country:US
Mailing Address - Phone:251-490-2026
Mailing Address - Fax:
Practice Address - Street 1:3510 MONTLIMAR PLAZA DR STE 100
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-1746
Practice Address - Country:US
Practice Address - Phone:251-635-4541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-129637163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty