Provider Demographics
NPI:1104196658
Name:MILLER, JENNIFER LEE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
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 1:4184 MILLER ST
Mailing Address - Street 2:PO BOX 900
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9713
Mailing Address - Country:US
Mailing Address - Phone:315-589-9665
Mailing Address - Fax:
Practice Address - Street 1:4184 MILLER ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:NY
Practice Address - Zip Code:14589-9713
Practice Address - Country:US
Practice Address - Phone:315-589-9665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY555175-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01391079Medicaid