Provider Demographics
NPI:1841557865
Name:MILLER, MAVALENE MAY DONNA
Entity Type:Individual
Prefix:MRS
First Name:MAVALENE
Middle Name:MAY DONNA
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 1:22 WOODSIDE KNOLLS DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-5064
Mailing Address - Country:US
Mailing Address - Phone:845-239-4966
Mailing Address - Fax:
Practice Address - Street 1:22 WOODSIDE KNOLLS DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-5064
Practice Address - Country:US
Practice Address - Phone:845-239-4966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-15
Last Update Date:2012-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291159-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse