Provider Demographics
NPI:1245452002
Name:MILLER, JAN MARIE (RD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 W GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6332
Mailing Address - Country:US
Mailing Address - Phone:580-585-5554
Mailing Address - Fax:580-355-5893
Practice Address - Street 1:3401 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6332
Practice Address - Country:US
Practice Address - Phone:580-585-5554
Practice Address - Fax:580-355-5893
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD 574133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic