Provider Demographics
NPI:1316647944
Name:MIRANDA, SANDRA ALEXANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:ALEXANDRA
Last Name:MIRANDA
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 1:27864 SW 139TH PATH
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6691
Mailing Address - Country:US
Mailing Address - Phone:786-236-8485
Mailing Address - Fax:
Practice Address - Street 1:11300 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-6628
Practice Address - Country:US
Practice Address - Phone:305-899-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390200000XMedicaid