Provider Demographics
NPI:1639895691
Name:MILLER, MARK DANIEL (APRN, AGACNP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DANIEL
Last Name:MILLER
Suffix:
Gender:
Credentials:APRN, AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2131
Mailing Address - Country:US
Mailing Address - Phone:860-460-6814
Mailing Address - Fax:
Practice Address - Street 1:1 CELLINI PL STE 102
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-1666
Practice Address - Country:US
Practice Address - Phone:203-932-6481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33688363LA2100X
CT12208363LA2200X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology