Provider Demographics
NPI:1134437304
Name:MILLER, JENNIFER LYNNE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNNE
Other - Last Name:SCARDINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6194
Mailing Address - Country:US
Mailing Address - Phone:309-762-3621
Mailing Address - Fax:309-762-3690
Practice Address - Street 1:520 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6194
Practice Address - Country:US
Practice Address - Phone:309-762-3621
Practice Address - Fax:309-762-3690
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4667363AM0700X
IL085.004094363A00000X
IA002207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical