Provider Demographics
NPI:1659379683
Name:MILLER, TRACI RAE (RN, MSN, CRNP)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:RAE
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN, MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 PINE TRL
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-1628
Mailing Address - Country:US
Mailing Address - Phone:410-340-3842
Mailing Address - Fax:
Practice Address - Street 1:6095 MARSHALEE DR
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6053
Practice Address - Country:US
Practice Address - Phone:410-379-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR117726363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD211140300Medicaid
MD892YMedicare ID - Type Unspecified
MD211140300Medicaid