Provider Demographics
NPI:1629010574
Name:MILLER, GAYLE MELINDA (FNP)
Entity Type:Individual
Prefix:MS
First Name:GAYLE
Middle Name:MELINDA
Last Name:MILLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 NE BRIDGETON RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-1051
Mailing Address - Country:US
Mailing Address - Phone:503-539-7884
Mailing Address - Fax:503-988-5112
Practice Address - Street 1:4610 SE BELMONT ST
Practice Address - Street 2:SUITE 60
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1752
Practice Address - Country:US
Practice Address - Phone:503-988-5303
Practice Address - Fax:503-988-5112
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR093007089N1 FNP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150907Medicaid
OR101561Medicare ID - Type Unspecified
OR150907Medicaid