Healthcare Provider Details

I. General information

NPI: 1639111891
Provider Name (Legal Business Name): BETHANY LUCIANI MILLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 NORWICH NEW LONDON TPKE
UNCASVILLE CT
06382-2527
US

IV. Provider business mailing address

80 NORWICH NEW LONDON TPKE
UNCASVILLE CT
06382-2527
US

V. Phone/Fax

Practice location:
  • Phone: 860-848-1297
  • Fax: 860-848-9875
Mailing address:
  • Phone: 860-848-1297
  • Fax: 860-848-9875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001434
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number1434
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: