Provider Demographics
NPI:1629392030
Name:MILLER, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
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 1:40 SHARYL DR
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-3473
Mailing Address - Country:US
Mailing Address - Phone:315-676-3206
Mailing Address - Fax:
Practice Address - Street 1:40 SHARYL DR
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-3473
Practice Address - Country:US
Practice Address - Phone:315-676-3206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229082164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse