Provider Demographics
NPI:1245730381
Name:REVIS, MIRANDA LOUISE (ATS)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LOUISE
Last Name:REVIS
Suffix:
Gender:F
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 PLEASANTDALE RD APT 8
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-6601
Mailing Address - Country:US
Mailing Address - Phone:330-469-0223
Mailing Address - Fax:
Practice Address - Street 1:1633 PLEASANTDALE RD APT 8
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-6601
Practice Address - Country:US
Practice Address - Phone:330-469-0223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program