Provider Demographics
NPI:1104653963
Name:THOMPSON, MIRANDA LEANNA (AT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEANNA
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17931 HIGHWAY 67 APT 101
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-2301
Mailing Address - Country:US
Mailing Address - Phone:229-449-2868
Mailing Address - Fax:
Practice Address - Street 1:17931 HIGHWAY 67 APT 101
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2301
Practice Address - Country:US
Practice Address - Phone:229-449-2868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program