Provider Demographics
NPI:1003630120
Name:MIRANDA, LINDA (RDN)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3356 E JAVELINA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-7330
Mailing Address - Country:US
Mailing Address - Phone:602-397-0455
Mailing Address - Fax:
Practice Address - Street 1:3356 E JAVELINA AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7330
Practice Address - Country:US
Practice Address - Phone:602-397-0455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT91341133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered