1114533536 NPI number — LYSSA ALEXANDRA MILLER APRN FNP-C

Table of content: MRS. DEBORAH ANN ROZAK LPTA (NPI 1386741379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114533536 NPI number — LYSSA ALEXANDRA MILLER APRN FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
LYSSA
Provider Middle Name:
ALEXANDRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114533536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 EASTERN PKWY APT C3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40204-1567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-472-0014
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5120 DIXIE HWY STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40216-1775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-448-7853
Provider Business Practice Location Address Fax Number:
502-448-0201
Provider Enumeration Date:
09/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  3015159 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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