Provider Demographics
NPI:1942826466
Name:MIRANDOU, KEVIN (FNP-CP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:MIRANDOU
Suffix:
Gender:M
Credentials:FNP-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 INDIAN CORNER RD
Mailing Address - Street 2:
Mailing Address - City:SAUNDERSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02874-2114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 CORLISS ST STE E
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2602
Practice Address - Country:US
Practice Address - Phone:401-793-2928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-20
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIF06200729363LF0000X
RIAPRN02408363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily