Provider Demographics
NPI:1144086109
Name:BALLARD, MIRANDA DIANNE (FNP-BC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:DIANNE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 VANGUARD DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-2132
Mailing Address - Country:US
Mailing Address - Phone:805-233-0242
Mailing Address - Fax:
Practice Address - Street 1:215 W JANSS RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1847
Practice Address - Country:US
Practice Address - Phone:805-370-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029217363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner