Provider Demographics
NPI:1013452671
Name:KLENOW, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:KLENOW
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 1:4048 EVANS AVE
Mailing Address - Street 2:STE 303
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9322
Mailing Address - Country:US
Mailing Address - Phone:239-332-5344
Mailing Address - Fax:239-332-7246
Practice Address - Street 1:4048 EVANS AVE
Practice Address - Street 2:STE 303
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9322
Practice Address - Country:US
Practice Address - Phone:239-332-5344
Practice Address - Fax:239-332-7246
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9374165367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered