Provider Demographics
NPI:1942485719
Name:MILLER, SANDRA GAYLE (FAM NURSE PRACTIONER)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:GAYLE
Last Name:MILLER
Suffix:
Gender:F
Credentials:FAM NURSE PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CARSON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2751
Mailing Address - Country:US
Mailing Address - Phone:719-383-5900
Mailing Address - Fax:
Practice Address - Street 1:1100 CARSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2751
Practice Address - Country:US
Practice Address - Phone:719-383-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-29
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP-5129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO74637801Medicaid