Basic Information
| Provider Information | |||||||||
| NPI: | 1063068955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTMILLER | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LVN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1343 W MAIN ST STE A | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953404438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097251060 | ||||||||
| FaxNumber: | 2097251064 | ||||||||
| Practice Location | |||||||||
| Address1: | 1343 W MAIN ST STE A&B | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953404438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097251060 | ||||||||
| FaxNumber: | 2097251064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2019 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 189332 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.