Provider Demographics
NPI:1841420106
Name:ACKERLEY, MIRANDA CHARISA (LPN IV)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:CHARISA
Last Name:ACKERLEY
Suffix:
Gender:F
Credentials:LPN IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5550 AUTUMN LEAF DR APT 7
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-1352
Mailing Address - Country:US
Mailing Address - Phone:937-409-9709
Mailing Address - Fax:877-350-2448
Practice Address - Street 1:5550 AUTUMN LEAF DR APT 7
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-1352
Practice Address - Country:US
Practice Address - Phone:937-409-9709
Practice Address - Fax:877-350-2448
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN128915IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse