Provider Demographics
NPI:1376898569
Name:WING, MIRANDA RENEE (APRN)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RENEE
Last Name:WING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:RENEE
Other - Last Name:WADDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:725 RESERVOIR AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4451
Mailing Address - Country:US
Mailing Address - Phone:401-829-4446
Mailing Address - Fax:401-829-4434
Practice Address - Street 1:725 RESERVOIR AVE STE 103
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4451
Practice Address - Country:US
Practice Address - Phone:401-829-4446
Practice Address - Fax:401-829-4434
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN01755363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2316320Medicaid
249644YJAMMedicare PIN