Provider Demographics
NPI:1902884687
Name:MIRANDA-VELAZQUEZ, ILEANA (CNS)
Entity Type:Individual
Prefix:MRS
First Name:ILEANA
Middle Name:
Last Name:MIRANDA-VELAZQUEZ
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-4127
Mailing Address - Country:US
Mailing Address - Phone:413-587-7500
Mailing Address - Fax:413-585-1355
Practice Address - Street 1:108 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-9595
Practice Address - Country:US
Practice Address - Phone:413-387-0075
Practice Address - Fax:413-387-0074
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA236837364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
P28210Medicare UPIN
MAMINS0458Medicare ID - Type Unspecified