Healthcare Provider Details

I. General information

NPI: 1154390276
Provider Name (Legal Business Name): MARY KAY MILLER ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4999 SKYLINE RD S
SALEM OR
97306-2878
US

IV. Provider business mailing address

PO BOX 1517
PENDLETON OR
97801-0410
US

V. Phone/Fax

Practice location:
  • Phone: 503-364-4005
  • Fax: 503-364-4006
Mailing address:
  • Phone: 877-708-1119
  • Fax: 541-278-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number088007213
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: