Provider Demographics
NPI:1528823705
Name:MCMAHAN, MIRANDA MARTIN
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:MARTIN
Last Name:MCMAHAN
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 1:3421 E CEDAR POINT DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523-9238
Mailing Address - Country:US
Mailing Address - Phone:309-402-2978
Mailing Address - Fax:
Practice Address - Street 1:330 SW ADAMS ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1502
Practice Address - Country:US
Practice Address - Phone:309-402-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily