Healthcare Provider Details

I. General information

NPI: 1194849950
Provider Name (Legal Business Name): MARY B MILLER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8710 MANCHESTER RD
SAINT LOUIS MO
63144-2724
US

IV. Provider business mailing address

PO BOX 1239
TROY MI
48099-1239
US

V. Phone/Fax

Practice location:
  • Phone: 314-941-3570
  • Fax: 314-961-6450
Mailing address:
  • Phone: 248-824-6600
  • Fax: 248-324-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number132345
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number132345
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: