Provider Demographics
NPI:1205650785
Name:MILLER, DIANNE R
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:R
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 1:2500 CANYON RD STE A1
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8492
Mailing Address - Country:US
Mailing Address - Phone:928-704-4499
Mailing Address - Fax:928-704-4949
Practice Address - Street 1:2500 CANYON RD STE A1
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8492
Practice Address - Country:US
Practice Address - Phone:928-704-4499
Practice Address - Fax:928-704-4949
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ318161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily