Provider Demographics
NPI:1861103137
Name:MILLER, ABIGAIL ROSE
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:ROSE
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N 81ST ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-2445
Mailing Address - Country:US
Mailing Address - Phone:804-543-5105
Mailing Address - Fax:
Practice Address - Street 1:111 N 81ST ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-2445
Practice Address - Country:US
Practice Address - Phone:804-543-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023033314363LP0808X
MO2020030713163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health