Provider Demographics
NPI:1295811792
Name:MILLER, ELAINE MARIE (CNP)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5506 N SHORE CT
Mailing Address - Street 2:
Mailing Address - City:MADISON LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56063-9521
Mailing Address - Country:US
Mailing Address - Phone:507-934-2207
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5066
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 073230-7363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN562312000Medicaid
MN562312000Medicaid