Provider Demographics
NPI:1841772472
Name:CASSITY, MIRANDA SUE (AGACNP-BC, FNP-BC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SUE
Last Name:CASSITY
Suffix:
Gender:F
Credentials:AGACNP-BC, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 E. STATE ROUTE 163
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-7327
Mailing Address - Country:US
Mailing Address - Phone:765-820-2120
Mailing Address - Fax:
Practice Address - Street 1:1764 E. STATE ROUTE 163
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-7327
Practice Address - Country:US
Practice Address - Phone:765-820-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008253A363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71008253AOtherAPN
IN28198899AOtherRN