1376328732 NPI number — MIRANDA ELYSE PEROTTI RN IBCLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376328732 NPI number — MIRANDA ELYSE PEROTTI RN IBCLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEROTTI
Provider First Name:
MIRANDA
Provider Middle Name:
ELYSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN IBCLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PALMER
Provider Other First Name:
MIRANDA
Provider Other Middle Name:
ELYSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376328732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3007 WOODLAND HILLS DR # 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77339-1403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-305-0411
Provider Business Mailing Address Fax Number:
281-572-0627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 WEST AVE UNIT 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78201-2822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-305-0411
Provider Business Practice Location Address Fax Number:
281-572-0627
Provider Enumeration Date:
08/25/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WL0100X , with the licence number:  878063 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com