Provider Demographics
NPI:1053854729
Name:MILLER, ANTOINETTE MARIE (NP)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:404 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948
Practice Address - Country:US
Practice Address - Phone:189-970-1666
Practice Address - Fax:618-998-8055
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015920363L00000X
IL209.015920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1053854729Medicaid