Provider Demographics
NPI:1316134992
Name:EVERETT, MILES EDWARD (RD, RN)
Entity type:Individual
Prefix:MR
First Name:MILES
Middle Name:EDWARD
Last Name:EVERETT
Suffix:
Gender:M
Credentials:RD, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 HICKORY HILL RD
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06787-1022
Mailing Address - Country:US
Mailing Address - Phone:347-406-4714
Mailing Address - Fax:
Practice Address - Street 1:80 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1418
Practice Address - Country:US
Practice Address - Phone:203-756-8021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000825133NN1002X
CT082032163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator