1790834166 NPI number — MRS. MARY DEDICK MILLER ANP,GNP

Table of content: MRS. MARY DEDICK MILLER ANP,GNP (NPI 1790834166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790834166 NPI number — MRS. MARY DEDICK MILLER ANP,GNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
MARY
Provider Middle Name:
DEDICK
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ANP,GNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790834166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 ENTERPRISE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUXBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02332-3307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-934-7144
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 WINTER ST
Provider Second Line Business Practice Location Address:
SUITE 3800
Provider Business Practice Location Address City Name:
WALTHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02451-1424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-472-8500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  MA , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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