Provider Demographics
NPI:1013306455
Name:MILLER, CLEMENTINE (ADULT NP)
Entity type:Individual
Prefix:
First Name:CLEMENTINE
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:ADULT NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 PHILLIP ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12306-1420
Mailing Address - Country:US
Mailing Address - Phone:617-838-5375
Mailing Address - Fax:
Practice Address - Street 1:1205 TROY SCHENECTADY RD STE 101
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1074
Practice Address - Country:US
Practice Address - Phone:518-348-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307173363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health