1124560487 NPI number — MIRANDA DAY NP

Table of content: MIRANDA DAY NP (NPI 1124560487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124560487 NPI number — MIRANDA DAY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAY
Provider First Name:
MIRANDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124560487
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 LEE CARTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37601-3094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-330-6320
Provider Business Mailing Address Fax Number:
865-330-6323

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
818 SUNSET DR
Provider Second Line Business Practice Location Address:
STE. 102
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-8310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-794-3142
Provider Business Practice Location Address Fax Number:
865-330-6323
Provider Enumeration Date:
11/17/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  21145 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4972149 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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