Provider Demographics
NPI:1114059169
Name:MILLER, MARY KATHLEEN (DNP, CNM, APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHLEEN
Last Name:MILLER
Suffix:
Gender:F
Credentials:DNP, CNM, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13300 GULF BLVD APT C
Mailing Address - Street 2:
Mailing Address - City:MADEIRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33708-2502
Mailing Address - Country:US
Mailing Address - Phone:407-716-9229
Mailing Address - Fax:
Practice Address - Street 1:3511 5TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-7501
Practice Address - Country:US
Practice Address - Phone:727-895-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3211042363LX0001X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3401731Medicaid