Provider Demographics
NPI:1063656106
Name:MILLER, JENIFER SUSAN (FNP)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:SUSAN
Last Name:MILLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1072
Mailing Address - Country:US
Mailing Address - Phone:706-369-4478
Mailing Address - Fax:706-353-6639
Practice Address - Street 1:125 KING AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6734
Practice Address - Country:US
Practice Address - Phone:706-369-4478
Practice Address - Fax:706-353-6639
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111545363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003128482BMedicaid
GA003128482CMedicaid
GA202I504878OtherMEDICARE PTAN