Provider Demographics
NPI:1336751130
Name:MOORE MILLER, MARY BETH (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:MOORE MILLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 US RT 60 EAST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-0313
Mailing Address - Country:US
Mailing Address - Phone:304-528-4600
Mailing Address - Fax:
Practice Address - Street 1:332 6TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1246
Practice Address - Country:US
Practice Address - Phone:304-380-7125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV104307363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily