Provider Demographics
NPI:1750933883
Name:MILLER, MARY LEE (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 BROOKS LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:COKATO
Mailing Address - State:MN
Mailing Address - Zip Code:55321-4635
Mailing Address - Country:US
Mailing Address - Phone:763-300-9688
Mailing Address - Fax:
Practice Address - Street 1:25 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1568
Practice Address - Country:US
Practice Address - Phone:763-682-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2474184163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health