Provider Demographics
NPI:1104940832
Name:MILLER, ELISE ROSE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:ROSE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22107 WOODLAND LN
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-9763
Mailing Address - Country:US
Mailing Address - Phone:763-498-8288
Mailing Address - Fax:
Practice Address - Street 1:3131 FERNBROOK LN N
Practice Address - Street 2:SUITE 102
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5321
Practice Address - Country:US
Practice Address - Phone:763-553-9097
Practice Address - Fax:763-553-9098
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2376237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist