Provider Demographics
NPI:1689388902
Name:MIREE, KANIQUE SHANTA (LMBT)
Entity type:Individual
Prefix:
First Name:KANIQUE
Middle Name:SHANTA
Last Name:MIREE
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SE MAYNARD RD STE 203
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-6945
Mailing Address - Country:US
Mailing Address - Phone:919-520-5868
Mailing Address - Fax:
Practice Address - Street 1:1230 SE MAYNARD RD STE 203
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6945
Practice Address - Country:US
Practice Address - Phone:919-520-5868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19142225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist