Individual
MIRANDA MALLICOAT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3900 KRESGE WAY STE 51, LOUISVILLE, KY 40207-4683
(502) 259-5955
Mailing address
5200 COMMERCE CROSSINGS DR FL 3, LOUISVILLE, KY 40229-2182
(502) 253-4924
(502) 489-5750
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
TSA026
KY
246ZC0007X
Surgical Assistant
Primary
TSA026
KY
Other
Enumeration date
02/21/2022
Last updated
03/09/2022
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