Provider Demographics
NPI:1548020134
Name:MALONE, MIRANDA DAWN (LE, LTA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:DAWN
Last Name:MALONE
Suffix:
Gender:F
Credentials:LE, LTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 E TERRA LN
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2750
Mailing Address - Country:US
Mailing Address - Phone:636-487-6200
Mailing Address - Fax:
Practice Address - Street 1:1055 E TERRA LN
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2750
Practice Address - Country:US
Practice Address - Phone:636-487-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024010331246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty