Provider Demographics
NPI:1043027113
Name:MIRANDA, GRISLEM
Entity type:Individual
Prefix:
First Name:GRISLEM
Middle Name:
Last Name:MIRANDA
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 1:23921 SW 106TH PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6152
Mailing Address - Country:US
Mailing Address - Phone:786-342-3809
Mailing Address - Fax:
Practice Address - Street 1:23921 SW 106TH PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6152
Practice Address - Country:US
Practice Address - Phone:786-342-3809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11036748363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care