Basic Information
| Provider Information | |||||||||
| NPI: | 1548491566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUNK-GARRETT | ||||||||
| FirstName: | MIRANDA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 RELIABLE PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096724809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1909 N MORTON AVE | ||||||||
| Address2: | |||||||||
| City: | MORTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615501426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092639124 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2009 | ||||||||
| LastUpdateDate: | 08/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209007704 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.