Provider Demographics
NPI:1992045652
Name:REID, MIRANDA MOLLIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:MOLLIE
Last Name:REID
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3427 KENTON ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-8344
Mailing Address - Country:US
Mailing Address - Phone:715-340-9514
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST
Practice Address - Street 2:STE 100
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-3301
Practice Address - Country:US
Practice Address - Phone:608-785-3638
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
WI191094-30163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health