Provider Demographics
NPI:1184387466
Name:MILLER, NICOLE LYNNE (LO)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LYNNE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2817
Mailing Address - Country:US
Mailing Address - Phone:860-940-4829
Mailing Address - Fax:
Practice Address - Street 1:812 PARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2417
Practice Address - Country:US
Practice Address - Phone:860-769-2020
Practice Address - Fax:860-769-2021
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADOP100067156FX1800X
CT1855156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician