1255973830 NPI number — AMY LEEANN MILLER APRN

Table of content: AMY LEEANN MILLER APRN (NPI 1255973830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255973830 NPI number — AMY LEEANN MILLER APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
AMY
Provider Middle Name:
LEEANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
AMY
Provider Other Middle Name:
LEEANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255973830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3988
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62902-3988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-457-5200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 LINCOLN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERRIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62948-3789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-993-0056
Provider Business Practice Location Address Fax Number:
618-993-0752
Provider Enumeration Date:
10/15/2019

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: 363L00000X , with the licence number:  209026434 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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