MEDICARE: STEPHANIE ANNETTE MILLER LICENSED OPTICIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	1994	NC

General Provider Information

NPI Number	:	1790040574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ANNETTE MILLER LICENSED OPTICIAN

Provider Business Mailing Address
First Line	:	1278 W OCEAN VIEW AVE
Second Line	:	#3
City	:	NORFOLK
State	:	VA
Zip	:	23503-1118
Country	:	US
Telephone Number	:	919-710-1449
Fax Number	:	757-275-9424

Provider Business Practice Location Address
First Line	:	1891 OAK GROVE CHURCH RD
Second Line	:
City	:	ELLENBORO
State	:	NC
Zip	:	28040-7694
Country	:	US
Telephone Number	:	919-710-1449
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2012
Last Update Date	:	07/09/2012

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