Provider Demographics
NPI:1700584984
Name:WHITEHEAD, MIRANDA ALEXIS-MARTIN
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ALEXIS-MARTIN
Last Name:WHITEHEAD
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 1:438 WALTONS MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:VA
Mailing Address - Zip Code:24127-8691
Mailing Address - Country:US
Mailing Address - Phone:540-588-8555
Mailing Address - Fax:
Practice Address - Street 1:438 WALTONS MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:VA
Practice Address - Zip Code:24127-8691
Practice Address - Country:US
Practice Address - Phone:540-588-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001280462163WI0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0600XNursing Service ProvidersRegistered NurseInfection Control