Provider Demographics
NPI:1548080740
Name:KRIDER, MYRANDA LESLEY (NP)
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:LESLEY
Last Name:KRIDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9649 W OLYMPIC BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3746
Mailing Address - Country:US
Mailing Address - Phone:760-780-8293
Mailing Address - Fax:
Practice Address - Street 1:9100 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-3415
Practice Address - Country:US
Practice Address - Phone:424-777-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-12
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95031288363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily