Provider Demographics
NPI:1740483114
Name:MILLER, BEVERLY JANE (LPN)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JANE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N HARTWELL AVE
Mailing Address - Street 2:UPPR
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-3814
Mailing Address - Country:US
Mailing Address - Phone:262-893-1278
Mailing Address - Fax:
Practice Address - Street 1:1001 DELAFIELD ST
Practice Address - Street 2:APT 320
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-547-6869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29122031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35000300Medicaid