Provider Demographics
NPI:1972020378
Name:MILLER- BAUER, KIM (PMHNP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:MILLER- BAUER
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16820 BALCH PL
Mailing Address - Street 2:
Mailing Address - City:MANNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13661-4283
Mailing Address - Country:US
Mailing Address - Phone:315-523-0681
Mailing Address - Fax:
Practice Address - Street 1:16820 BALCH PLACE
Practice Address - Street 2:
Practice Address - City:MANNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13661
Practice Address - Country:US
Practice Address - Phone:315-523-0681
Practice Address - Fax:315-523-0681
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402155-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty