Provider Demographics
NPI:1073143327
Name:MILES, JACQUELINE (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MILES
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 1:5224 S STATE HIGHWAY 360
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0950
Mailing Address - Country:US
Mailing Address - Phone:972-552-0691
Mailing Address - Fax:972-522-1053
Practice Address - Street 1:5224 S STATE HIGHWAY 360 STE 230
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-0964
Practice Address - Country:US
Practice Address - Phone:972-522-0691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX874631363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care