Provider Demographics
NPI:1316774409
Name:MIRANDA, KRYSTEL DYANN
Entity type:Individual
Prefix:
First Name:KRYSTEL
Middle Name:DYANN
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 1:726 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3221
Mailing Address - Country:US
Mailing Address - Phone:951-751-7434
Mailing Address - Fax:
Practice Address - Street 1:4141 S NOGALES ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-3056
Practice Address - Country:US
Practice Address - Phone:833-831-8946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician