Provider Demographics
NPI:1528045457
Name:MILLER, SUSAN T (APRN,BC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:T
Last Name:MILLER
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2528 DEARBORN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3512
Mailing Address - Country:US
Mailing Address - Phone:801-466-5978
Mailing Address - Fax:
Practice Address - Street 1:3809 W 6200 S
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-3725
Practice Address - Country:US
Practice Address - Phone:801-963-4213
Practice Address - Fax:801-963-4299
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1953014405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT104502OtherU005
UT107002817101OtherU006
UT262112OtherU002