Provider Demographics
NPI:1538602289
Name:MCWILLIAMS, MIRANDA NICOLE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NICOLE
Last Name:MCWILLIAMS
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 1:507 BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2308
Mailing Address - Country:US
Mailing Address - Phone:505-620-2992
Mailing Address - Fax:
Practice Address - Street 1:507 BROWN AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2308
Practice Address - Country:US
Practice Address - Phone:505-620-2992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000011978OtherBOARD OF CERTIFICATION