Provider Demographics
NPI:1700549359
Name:MIRA, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MIRA
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 1:4053 62ND ST APT WOODSIDE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-8613
Mailing Address - Country:US
Mailing Address - Phone:718-473-6407
Mailing Address - Fax:
Practice Address - Street 1:4053 62ND ST APT WOODSIDE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-8613
Practice Address - Country:US
Practice Address - Phone:718-473-6407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY801707163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse