Provider Demographics
NPI:1932637725
Name:VANCIL, MIRANDA LARAE (APRN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LARAE
Last Name:VANCIL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:MIRANDA
Other - Middle Name:LARAE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1410 N WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2953
Mailing Address - Country:US
Mailing Address - Phone:316-788-3741
Mailing Address - Fax:316-788-5198
Practice Address - Street 1:1410 N WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2953
Practice Address - Country:US
Practice Address - Phone:316-788-3741
Practice Address - Fax:316-788-5198
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-77657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSPENDINGMedicaid