Provider Demographics
NPI:1447620703
Name:MILLER, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 RHONDA RHEAULT DR # 1
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01540-2300
Mailing Address - Country:US
Mailing Address - Phone:774-670-8566
Mailing Address - Fax:
Practice Address - Street 1:1185 MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2093
Practice Address - Country:US
Practice Address - Phone:860-423-7556
Practice Address - Fax:860-423-4694
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN255546367500000X
NHEL11037367500000X
CT6781367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered