Provider Demographics
NPI:1467584524
Name:MILLER, DIANA R
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:R
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 1:2930 LURTING AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-4016
Mailing Address - Country:US
Mailing Address - Phone:646-641-1750
Mailing Address - Fax:
Practice Address - Street 1:4377 BRONX BLVD
Practice Address - Street 2:SUITE202
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1397
Practice Address - Country:US
Practice Address - Phone:718-519-7672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277902164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02798790Medicaid