Provider Demographics
NPI:1801495056
Name:MILLER, CONNIE L
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5825 CATALPA AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5001
Mailing Address - Country:US
Mailing Address - Phone:718-381-8003
Mailing Address - Fax:718-381-3519
Practice Address - Street 1:5825 CATALPA AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5001
Practice Address - Country:US
Practice Address - Phone:718-381-8003
Practice Address - Fax:718-381-3519
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY355863163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool