Provider Demographics
NPI:1093045254
Name:MCMILLAN, GWEN (ACNP)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24562 CHRISTIAN DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48134-9113
Mailing Address - Country:US
Mailing Address - Phone:313-587-7165
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-10
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704157067363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care