Provider Demographics
NPI:1992045645
Name:MIRANDA, MARYANNE S
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:S
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 1:436 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-5910
Mailing Address - Country:US
Mailing Address - Phone:201-616-2379
Mailing Address - Fax:
Practice Address - Street 1:377 JERSEY AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4393
Practice Address - Country:US
Practice Address - Phone:201-499-3897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR14519200163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ35-2321534OtherLUTHERAN SENIOR LIFE AT JERSEY CITY