Basic Information
Provider Information | |||||||||
NPI: | 1437678810 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEWELL | ||||||||
FirstName: | MIRANDA | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STAPLES | ||||||||
OtherFirstName: | MIRANDA | ||||||||
OtherMiddleName: | JO | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1080 | ||||||||
Address2: |   | ||||||||
City: | BURKESVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 427171080 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2708586644 | ||||||||
FaxNumber: | 2708584027 | ||||||||
Practice Location | |||||||||
Address1: | 301 PROFESSIONAL PARK DR | ||||||||
Address2: |   | ||||||||
City: | GLASGOW | ||||||||
State: | KY | ||||||||
PostalCode: | 421413487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2706519696 | ||||||||
FaxNumber: | 2706510385 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2017 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 3011720 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 3011720 | 01 | KY | KENTUCKY MEDICAL LICENSE | OTHER |