Provider Demographics
NPI:1932487931
Name:ABBOTT, MIRANDA
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2561 E CALUMET ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4748
Mailing Address - Country:US
Mailing Address - Phone:920-243-7140
Mailing Address - Fax:877-346-6682
Practice Address - Street 1:2561 E CALUMET ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4748
Practice Address - Country:US
Practice Address - Phone:920-243-7140
Practice Address - Fax:877-346-6682
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4759-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor