Basic Information
| Provider Information | |||||||||
| NPI: | 1942528252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BC-ACNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | MARTI | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BC-ACNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 724 LAKE DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884352559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754724311 | ||||||||
| FaxNumber: | 5754724313 | ||||||||
| Practice Location | |||||||||
| Address1: | 724 LAKE DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884352559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754724311 | ||||||||
| FaxNumber: | 5754724313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2010 | ||||||||
| LastUpdateDate: | 04/22/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | CNP-01641 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.