Provider Demographics
NPI:1629121595
Name:MILLER, CAROL M (FNP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:MILLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:KOENIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5675
Mailing Address - Country:US
Mailing Address - Phone:701-222-3937
Mailing Address - Fax:701-222-8805
Practice Address - Street 1:3119 N 14TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503
Practice Address - Country:US
Practice Address - Phone:701-222-3937
Practice Address - Fax:701-222-8805
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR22755363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1452852Medicaid
ND1452852Medicaid
NDN22638Medicare PIN
ND19610Medicaid