Provider Demographics
NPI:1306673165
Name:ANTIMO, MIRANDA MARIE (DNAP, CRNA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MARIE
Last Name:ANTIMO
Suffix:
Gender:F
Credentials:DNAP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 OLD STAGECOACH RD
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-7601
Mailing Address - Country:US
Mailing Address - Phone:501-837-2945
Mailing Address - Fax:
Practice Address - Street 1:300 WERNER ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6406
Practice Address - Country:US
Practice Address - Phone:501-622-1000
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 Licenses
StateLicense IDTaxonomies
AR230495367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered