Provider Demographics
NPI:1730737214
Name:BAUMGUARDNER, MIRANDA ELLISA (FNP-C)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELLISA
Last Name:BAUMGUARDNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5001
Mailing Address - Country:US
Mailing Address - Phone:432-640-1883
Mailing Address - Fax:
Practice Address - Street 1:500 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5001
Practice Address - Country:US
Practice Address - Phone:432-640-1883
Practice Address - Fax:432-640-2428
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137886363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily