Provider Demographics
NPI:1649200585
Name:MILLER, MARILYN (NP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2000
Mailing Address - Country:US
Mailing Address - Phone:518-828-8363
Mailing Address - Fax:518-697-3388
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2907
Practice Address - Country:US
Practice Address - Phone:518-697-3540
Practice Address - Fax:518-697-3551
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333618363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02406751Medicaid
P78373Medicare UPIN
NY02406751Medicaid