Provider Demographics
NPI:1801614227
Name:MOGLE, MIRANDA JOY (DNP)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:JOY
Last Name:MOGLE
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 EAGLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-2007
Mailing Address - Country:US
Mailing Address - Phone:217-741-7802
Mailing Address - Fax:
Practice Address - Street 1:232 EAGLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-2007
Practice Address - Country:US
Practice Address - Phone:217-741-7802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030896363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner