Provider Demographics
NPI:1790924595
Name:MILLER, PAULETTE MAUREEN (LPN)
Entity Type:Individual
Prefix:MS
First Name:PAULETTE
Middle Name:MAUREEN
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 WALTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-9512
Mailing Address - Country:US
Mailing Address - Phone:678-428-4351
Mailing Address - Fax:
Practice Address - Street 1:9 W PROSPECT AVE STE 310
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2049
Practice Address - Country:US
Practice Address - Phone:914-699-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211564-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY211564-1Medicaid