Healthcare Provider Details

I. General information

NPI: 1003239310
Provider Name (Legal Business Name): MYKALENE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1559 WATASHEAMU RD
GARDNERVILLE NV
89460-7455
US

IV. Provider business mailing address

1559 WATASHEAMU RD
GARDNERVILLE NV
89460-7455
US

V. Phone/Fax

Practice location:
  • Phone: 775-265-4215
  • Fax: 775-265-9248
Mailing address:
  • Phone: 775-265-4215
  • Fax: 775-265-9248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPT12678
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: