Provider Demographics
NPI:1508100744
Name:MILLER, MICHELLE MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
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 1:2503 12TH ST.
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829
Mailing Address - Country:US
Mailing Address - Phone:515-432-5433
Mailing Address - Fax:
Practice Address - Street 1:2503 12TH ST.
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829
Practice Address - Country:US
Practice Address - Phone:715-822-3567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-10
Last Update Date:2016-03-16
Deactivation Date:2013-10-24
Deactivation Code:
Reactivation Date:2016-03-14
Provider Licenses
StateLicense IDTaxonomies
IAP44034164W00000X
WI318716164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse