Healthcare Provider Details

I. General information

NPI: 1174107130
Provider Name (Legal Business Name): DALE ROBERT MILLER PMNHP-BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 HILLSIDE PL
ILION NY
13357-2109
US

IV. Provider business mailing address

17603 LONG RIDGE DR
MONTVERDE FL
34756-4011
US

V. Phone/Fax

Practice location:
  • Phone: 646-858-1804
  • Fax: 315-363-9286
Mailing address:
  • Phone: 315-601-3548
  • Fax: 315-363-9286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF403411
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: