Basic Information
| Provider Information | |||||||||
| NPI: | 1295811792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5506 N SHORE CT | ||||||||
| Address2: | |||||||||
| City: | MADISON LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560639521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5079342207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1230 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560015066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R 073230-7 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 562312000 | 05 | MN | MEDICAID |