Provider Demographics
NPI:1023659901
Name:CUNNINGHAM, MIRANDA S
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:S
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 BELFORT RD STE 305
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8210
Mailing Address - Country:US
Mailing Address - Phone:904-448-0046
Mailing Address - Fax:904-448-0056
Practice Address - Street 1:3840 BELFORT RD STE 305
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8210
Practice Address - Country:US
Practice Address - Phone:904-448-0046
Practice Address - Fax:904-448-0056
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA93569225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist