Provider Demographics
NPI:1518577980
Name:MILLER, MADISON (MSN, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4154 MOSER LN
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7183
Mailing Address - Country:US
Mailing Address - Phone:269-873-9617
Mailing Address - Fax:
Practice Address - Street 1:710 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3224
Practice Address - Country:US
Practice Address - Phone:419-334-6619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLE-00033495363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0419613Medicaid