Healthcare Provider Details

I. General information

NPI: 1417750118
Provider Name (Legal Business Name): CHEYENNE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 S BROAD ST UNIT 4
LANSDALE PA
19446-3703
US

IV. Provider business mailing address

419 S BROAD ST UNIT 4
LANSDALE PA
19446-3703
US

V. Phone/Fax

Practice location:
  • Phone: 215-536-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA066719
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: