Provider Demographics
NPI:1386078756
Name:BOSS, MIRANDA (DPT, ATC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BOSS
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, ATC
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:888-201-1040
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:1258 W SOUTH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-8300
Practice Address - Country:US
Practice Address - Phone:309-852-2200
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-020103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
F400097436Medicare PIN