Provider Demographics
NPI:1417221094
Name:MILLER, SHIRLEY A (LPN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:A
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 YORKSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-1034
Mailing Address - Country:US
Mailing Address - Phone:315-487-3523
Mailing Address - Fax:
Practice Address - Street 1:2105 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-1698
Practice Address - Country:US
Practice Address - Phone:315-468-3239
Practice Address - Fax:315-468-2917
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112436164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY112436OtherLPN LICENSE