Provider Demographics
NPI:1659639045
Name:MILLER, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
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 1:1811 FAULKNER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-6062
Mailing Address - Country:US
Mailing Address - Phone:951-378-5391
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36408167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician