Provider Demographics
NPI:1700158565
Name:ST. JOHN, MARANDA JANE
Entity Type:Individual
Prefix:MRS
First Name:MARANDA
Middle Name:JANE
Last Name:ST. JOHN
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 1:127 OLD MONTICELLO ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-2357
Mailing Address - Country:US
Mailing Address - Phone:606-271-7878
Mailing Address - Fax:606-678-2723
Practice Address - Street 1:127 OLD MONTICELLO ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-2357
Practice Address - Country:US
Practice Address - Phone:606-271-7878
Practice Address - Fax:606-678-2723
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201132385222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist