Provider Demographics
NPI:1427501378
Name:HANDYSIDE, MIRANDA M
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:M
Last Name:HANDYSIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:WHITESELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 S HEALTH PARKWAY STE 1
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8354
Practice Address - Country:US
Practice Address - Phone:269-273-8557
Practice Address - Fax:269-279-6461
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704273097363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1427501378Medicaid