Provider Demographics
NPI:1487309290
Name:MALLICOAT, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MALLICOAT
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 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:3900 KRESGE WAY STE 51
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4683
Practice Address - Country:US
Practice Address - Phone:502-259-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTSA026208600000X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty