Provider Demographics
NPI:1568356152
Name:ICKLER, MIRANDA A
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:A
Last Name:ICKLER
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 1:2266 RULE AVE APT D
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-1430
Mailing Address - Country:US
Mailing Address - Phone:314-806-1248
Mailing Address - Fax:
Practice Address - Street 1:12521 MARINE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-2411
Practice Address - Country:US
Practice Address - Phone:314-806-1248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-06
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach