Provider Demographics
NPI:1053615013
Name:GRIDER, MIRANDA D (NP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:D
Last Name:GRIDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:D
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:116 BIBLE XING
Mailing Address - Street 2:
Mailing Address - City:DECHERD
Mailing Address - State:TN
Mailing Address - Zip Code:37324-3886
Mailing Address - Country:US
Mailing Address - Phone:319-681-2369
Mailing Address - Fax:931-968-1241
Practice Address - Street 1:116 BIBLE XING
Practice Address - Street 2:
Practice Address - City:DECHERD
Practice Address - State:TN
Practice Address - Zip Code:37324-3886
Practice Address - Country:US
Practice Address - Phone:319-681-2369
Practice Address - Fax:931-968-1241
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0990080-NP363L00000X
CO178965363L00000X
TN28561363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner