Healthcare Provider Details

I. General information

NPI: 1891719951
Provider Name (Legal Business Name): BETTY S MILLER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2142 WECOMA PL
ILWACO WA
98624-0430
US

IV. Provider business mailing address

PO BOX 430
ILWACO WA
98624-0430
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-4821
  • Fax:
Mailing address:
  • Phone: 360-642-4821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30004492
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: