Provider Demographics
NPI:1942802434
Name:MILLER, SUSAN L
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
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 1:11752 MARBURGER RD SW
Mailing Address - Street 2:
Mailing Address - City:STOUTSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43154-9518
Mailing Address - Country:US
Mailing Address - Phone:740-412-6749
Mailing Address - Fax:
Practice Address - Street 1:1660 DELAWARE TRL
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-8306
Practice Address - Country:US
Practice Address - Phone:740-412-6749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0317440Medicaid