Provider Demographics
NPI:1457813123
Name:COLEMAN, MIRANDA JEANETTE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JEANETTE
Last Name:COLEMAN
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:PO BOX 1271
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-0927
Mailing Address - Country:US
Mailing Address - Phone:360-609-4022
Mailing Address - Fax:
Practice Address - Street 1:3400 SE 196TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-8862
Practice Address - Country:US
Practice Address - Phone:360-609-4022
Practice Address - Fax:360-210-4200
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60687443225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist