Basic Information
| Provider Information | |||||||||
| NPI: | 1679062731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILES | ||||||||
| FirstName: | MARANDA | ||||||||
| MiddleName: | WORTHAM | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1258 | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384851258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312531110 | ||||||||
| FaxNumber: | 9317229919 | ||||||||
| Practice Location | |||||||||
| Address1: | 2242 HWY 41 NORTH | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709714831 | ||||||||
| FaxNumber: | 2709714832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2018 | ||||||||
| LastUpdateDate: | 05/04/2018 | ||||||||
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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 | 363LF0000X | 3012216 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.