Provider Demographics
NPI:1891015467
Name:GOFORTH, MIRANDA LEE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:LEE
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:MIRANDA
Other - Middle Name:LEE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:146 PASSION PLAY RD STE A
Mailing Address - Street 2:
Mailing Address - City:EUREKA SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72632-9455
Mailing Address - Country:US
Mailing Address - Phone:479-253-9746
Mailing Address - Fax:
Practice Address - Street 1:146 PASSION PLAY RD STE A
Practice Address - Street 2:
Practice Address - City:EUREKA SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72632-9455
Practice Address - Country:US
Practice Address - Phone:479-253-9746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR874514163W00000X
TN15025363LF0000X
AR218923363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse