Provider Demographics
NPI:1356121404
Name:MIRANDA CHUMPITAZ, FLORENCIA KARINA (NP)
Entity type:Individual
Prefix:
First Name:FLORENCIA
Middle Name:KARINA
Last Name:MIRANDA CHUMPITAZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 672
Mailing Address - Street 2:
Mailing Address - City:COBB
Mailing Address - State:CA
Mailing Address - Zip Code:95426-0672
Mailing Address - Country:US
Mailing Address - Phone:707-513-6002
Mailing Address - Fax:
Practice Address - Street 1:359 LAKEPORT BLVD
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5412
Practice Address - Country:US
Practice Address - Phone:707-513-6002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027548363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care