Provider Demographics
NPI:1346794468
Name:WIKERT, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:WIKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:FUGATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2036 SADDLEBACK DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-9493
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2036 SADDLEBACK DR
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-9493
Practice Address - Country:US
Practice Address - Phone:909-936-4861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1631127163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse