Provider Demographics
NPI:1467202192
Name:MILLER, MARIE VICTORIA
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:VICTORIA
Last Name:MILLER
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 1:7654 THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-2834
Mailing Address - Country:US
Mailing Address - Phone:415-221-4810
Mailing Address - Fax:
Practice Address - Street 1:7654 THORNTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-2834
Practice Address - Country:US
Practice Address - Phone:415-221-4810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA994183136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered