Provider Demographics
NPI:1285387886
Name:GONZALEZ, MIRANDA LEA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEA
Last Name:GONZALEZ
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 1:801 W SR 436 STE 2015
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3053
Mailing Address - Country:US
Mailing Address - Phone:407-285-4789
Mailing Address - Fax:
Practice Address - Street 1:801 W SR 436 STE 2015
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-3053
Practice Address - Country:US
Practice Address - Phone:407-285-4789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL238214376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL238214Medicaid