Provider Demographics
NPI:1831102748
Name:MILLS, MARCY B (NP)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:B
Last Name:MILLS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9367
Mailing Address - Country:US
Mailing Address - Phone:315-785-4155
Mailing Address - Fax:315-779-5066
Practice Address - Street 1:1575 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9367
Practice Address - Country:US
Practice Address - Phone:315-785-4155
Practice Address - Fax:315-779-5066
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300062363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354316Medicaid
NY00354316Medicaid