Provider Demographics
NPI:1629435060
Name:MILLER, COURTNEY STANFORD (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:STANFORD
Last Name:MILLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BOULEVARD
Mailing Address - Street 2:STE 3D
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1866
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:20060 GOVERNORS DR
Practice Address - Street 2:SUITE 102
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1029
Practice Address - Country:US
Practice Address - Phone:815-824-4406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013548363L00000X
MI4704276415363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner