Provider Demographics
NPI:1184382137
Name:KING, MIRANDA (NP - C)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:NP - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 BRIGHT LEAF LN
Mailing Address - Street 2:
Mailing Address - City:FOLKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:31537-7619
Mailing Address - Country:US
Mailing Address - Phone:912-276-1265
Mailing Address - Fax:
Practice Address - Street 1:172 BRIGHT LEAF LN
Practice Address - Street 2:
Practice Address - City:FOLKSTON
Practice Address - State:GA
Practice Address - Zip Code:31537-7619
Practice Address - Country:US
Practice Address - Phone:912-276-1265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11019942363LF0000X
GARN282254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily