Basic Information
| Provider Information | |||||||||
| NPI: | 1952344699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 677 CATHEDRAL DR | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577016018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053439224 | ||||||||
| FaxNumber: | 6053421359 | ||||||||
| Practice Location | |||||||||
| Address1: | 636 SAINT ANNE ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577014694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053488000 | ||||||||
| FaxNumber: | 6053484315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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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 | R0148350250 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LX0001X | R0148350250 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 363LP0808X | CP000250 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 6826173 | 05 | SD | MEDICAID |