Healthcare Provider Details

I. General information

NPI: 1144599515
Provider Name (Legal Business Name): EVANGELINA PAVELIK MILLER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 W 4TH ST
BENSON AZ
85602-6437
US

IV. Provider business mailing address

2202 N FORBES BLVD
TUCSON AZ
85745-1412
US

V. Phone/Fax

Practice location:
  • Phone: 520-586-3664
  • Fax:
Mailing address:
  • Phone: 520-872-7536
  • Fax: 520-872-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4315
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: