Healthcare Provider Details

I. General information

NPI: 1164597647
Provider Name (Legal Business Name): SUSAN MILLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 E STOUGHTON ST
CHAMPAIGN IL
61820-5414
US

IV. Provider business mailing address

219 N CENTER ST
FARMER CITY IL
61842-1239
US

V. Phone/Fax

Practice location:
  • Phone: 217-359-8022
  • Fax:
Mailing address:
  • Phone: 309-928-3110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: