Provider Demographics
NPI:1326391830
Name:MILLERT, ANN MARIE
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:MARIE
Last Name:MILLERT
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 1:220 W KENNEDY ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-1057
Mailing Address - Country:US
Mailing Address - Phone:315-435-4276
Mailing Address - Fax:315-435-6553
Practice Address - Street 1:220 W KENNEDY ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-1057
Practice Address - Country:US
Practice Address - Phone:315-435-4276
Practice Address - Fax:315-435-6553
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191134172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker