MEDICARE: MARY KAY MILLER ANP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	088007213	OR

General Provider Information

NPI Number	:	1154390276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KAY MILLER ANP

Provider Business Mailing Address
First Line	:	PO BOX 1517
Second Line	:
City	:	PENDLETON
State	:	OR
Zip	:	97801-0410
Country	:	US
Telephone Number	:	877-708-1119
Fax Number	:	541-278-8349

Provider Business Practice Location Address
First Line	:	4999 SKYLINE RD S
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97306-2878
Country	:	US
Telephone Number	:	503-364-4005
Fax Number	:	503-364-4006

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	02/06/2023

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