Provider Demographics
NPI:1003970856
Name:MILLER, LISA LYNETTE (ARNP, BSN, MN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNETTE
Last Name:MILLER
Suffix:
Gender:F
Credentials:ARNP, BSN, MN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 CAMPUS RIDGE DR STE 4000
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-839-3393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650026NP ACNP-PP363LA2200X
WAAP30007900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0248141OtherLABOR & INDUSTRIES
WA9654609Medicaid
OR200650026NP ACNP-PPOtherOR LICENSE
WA2005009787-21OtherWA LIC
WA2005009787-21OtherWA LIC
WAMM1390727OtherDEA
WAQ76027Medicare PIN