Provider Demographics
NPI:1679062731
Name:MILES, MARANDA WORTHAM (APRN)
Entity type:Individual
Prefix:
First Name:MARANDA
Middle Name:WORTHAM
Last Name:MILES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-1258
Mailing Address - Country:US
Mailing Address - Phone:931-253-1110
Mailing Address - Fax:931-722-9919
Practice Address - Street 1:2242 HWY 41 NORTH
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420
Practice Address - Country:US
Practice Address - Phone:270-971-4831
Practice Address - Fax:270-971-4832
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012216363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily