Provider Demographics
NPI:1982187340
Name:MIRANDA, MARJORIE G
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:G
Last Name:MIRANDA
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 1:358 SAINT MARKS PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2417
Mailing Address - Country:US
Mailing Address - Phone:646-942-7897
Mailing Address - Fax:
Practice Address - Street 1:131 BEACH ST # 1
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2235
Practice Address - Country:US
Practice Address - Phone:347-520-2077
Practice Address - Fax:347-520-2077
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program