Provider Demographics
NPI:1073801734
Name:MILLER, MICHELLE K (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:K
Last Name:MILLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:K
Other - Last Name:CRAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:800-732-1066
Mailing Address - Fax:317-962-4343
Practice Address - Street 1:777 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-2493
Practice Address - Country:US
Practice Address - Phone:765-828-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28179417A363L00000X
IL209018042363LF0000X
IN71003631A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily