Healthcare Provider Details

I. General information

NPI: 1811650518
Provider Name (Legal Business Name): BETHANIE MICHELLE MILLER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 LEGACY PKWY E STE 100
MAPLEWOOD MN
55109-5434
US

IV. Provider business mailing address

7235 OHMS LN
EDINA MN
55439-2148
US

V. Phone/Fax

Practice location:
  • Phone: 952-841-2345
  • Fax: 952-841-2346
Mailing address:
  • Phone: 952-841-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8599
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: