Provider Demographics
NPI:1184845935
Name:MILLER RANNESTAD, SUSAN (CM, LM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MILLER RANNESTAD
Suffix:
Gender:F
Credentials:CM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 BOYCE RD
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-6809
Mailing Address - Country:US
Mailing Address - Phone:845-744-5219
Mailing Address - Fax:845-744-5219
Practice Address - Street 1:209 BOYCE RD
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-6809
Practice Address - Country:US
Practice Address - Phone:845-282-2229
Practice Address - Fax:845-744-5219
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001271367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife