Provider Demographics
NPI:1417002981
Name:MILLER, SUSAN ELIZABETH (RN, MA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 E BADGER RD
Mailing Address - Street 2:
Mailing Address - City:EVERSON
Mailing Address - State:WA
Mailing Address - Zip Code:98247-9329
Mailing Address - Country:US
Mailing Address - Phone:360-966-7059
Mailing Address - Fax:360-966-2239
Practice Address - Street 1:112 S 6TH ST
Practice Address - Street 2:UNIT B
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1993
Practice Address - Country:US
Practice Address - Phone:369-354-1191
Practice Address - Fax:360-354-1191
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001772106H00000X
WARN0018429163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUBI 601 786 753OtherWA BUSINESS LICENSE NUMBE