Provider Demographics
NPI:1518703933
Name:BLACK, MIRANDA A (LPN)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:A
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-3787
Mailing Address - Country:US
Mailing Address - Phone:904-466-7339
Mailing Address - Fax:
Practice Address - Street 1:2230 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-3159
Practice Address - Country:US
Practice Address - Phone:904-466-7339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-04
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5169477164W00000X
FL9674808163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse