Provider Demographics
NPI:1093474801
Name:MILLER, MACKENNA
Entity Type:Individual
Prefix:
First Name:MACKENNA
Middle Name:
Last Name:MILLER
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 1:80 LESLIE LN
Mailing Address - Street 2:
Mailing Address - City:NEW COLUMBIA
Mailing Address - State:PA
Mailing Address - Zip Code:17856-9390
Mailing Address - Country:US
Mailing Address - Phone:814-357-5163
Mailing Address - Fax:
Practice Address - Street 1:100 FRONT ST STE 280
Practice Address - Street 2:
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-2891
Practice Address - Country:US
Practice Address - Phone:215-860-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist