Provider Demographics
NPI:1841802121
Name:MILLER, MATTHEW (RN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 WALKER AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4067
Mailing Address - Country:US
Mailing Address - Phone:616-235-2910
Mailing Address - Fax:
Practice Address - Street 1:1256 WALKER AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4067
Practice Address - Country:US
Practice Address - Phone:616-235-2910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704339921163W00000X, 163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice
No163W00000XNursing Service ProvidersRegistered Nurse