Provider Demographics
NPI:1023037629
Name:MILLER, GAIL GREEN (CRNA)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:GREEN
Last Name:MILLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:GAIL
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:123 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-3416
Mailing Address - Country:US
Mailing Address - Phone:662-256-7112
Mailing Address - Fax:
Practice Address - Street 1:1105 EARL FRYE BLVD
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5500
Practice Address - Country:US
Practice Address - Phone:662-256-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR133670367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS430001947Medicare ID - Type Unspecified