Provider Demographics
NPI:1083227375
Name:MILLER, TRACEY (RN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 TECHNOLOGY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-8126
Mailing Address - Country:US
Mailing Address - Phone:269-250-8009
Mailing Address - Fax:
Practice Address - Street 1:6480 TECHNOLOGY AVE STE A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-8126
Practice Address - Country:US
Practice Address - Phone:269-250-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704202059163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care