Provider Demographics
NPI:1548844426
Name:GAVINA, MIRANDA MARIE (LVN)
Entity type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:MARIE
Last Name:GAVINA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 20TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1228
Mailing Address - Country:US
Mailing Address - Phone:903-532-1400
Mailing Address - Fax:
Practice Address - Street 1:6901 67TH ST UNIT A
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-3039
Practice Address - Country:US
Practice Address - Phone:806-316-6470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352097164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse