Provider Demographics
NPI:1104359769
Name:MILLER, SHARLENE
Entity Type:Individual
Prefix:
First Name:SHARLENE
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 1:1571 11TH AVE EAST
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-5759
Mailing Address - Country:US
Mailing Address - Phone:701-205-4772
Mailing Address - Fax:
Practice Address - Street 1:1800 21ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5759
Practice Address - Country:US
Practice Address - Phone:701-205-4772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical