=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568577880
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIANNE MILES NP, PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 01/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 NORTH ST STE G
-----------------------------------------------------
City | CANANDAIGUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14424-1053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-455-0068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5770 SMITH RD
-----------------------------------------------------
City | CANANDAIGUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14424-8927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-396-0406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 400699
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------