Provider Demographics
NPI:1043717002
Name:WRIGHT, MIRANDA NICHOLE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NICHOLE
Last Name:WRIGHT
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 1:1285 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5518
Mailing Address - Country:US
Mailing Address - Phone:707-263-5163
Mailing Address - Fax:707-263-5166
Practice Address - Street 1:1285 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5518
Practice Address - Country:US
Practice Address - Phone:707-263-5163
Practice Address - Fax:707-263-5166
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49270OtherPHYSICAL THERAPY BOARD OF CALIFORNIA